Healing Alps: Tourism based on natural health resources as strategic innovation for the development of Alpine regions ASP815
Synthesis Report on HEALPS’ main outputs: WP 2: Medical-scientific characterization of Alpine Health Resources
WP T1: Assessment of Alpine regions’ Health Tourism Policy and Development Process
D.T1.1.1: Synthesis report on HEALPS’ main outputs (I/IV)
Lead Partner Paracelsus Medical University Salzburg Institute of Ecomedicine
Authors: Christina Pichler, Renate Weißböck-Erdheim, Johanna Freidl, Carina Ro- modow, Michael Bischof, Arnulf Hartl
Contact: [email protected]
Healing Alps: Tourism based on natural health resources as strategic innovation for the development of Alpine regions ASP815
Content
1 Report context 3 1.1 ARPAF project HEALPS 3 1.2 Alpine Space Project HEALPS 2 5 2 Identification of Alpine natural health resources 6 3 Characterization of Alpine natural health Resources: Medical Evidence and Checklist for Health Tourism Development 7 3.1 Methodological Approach 7 3.2 Medical-scientific characterization & Checklist 10 3.2.1 Air ions 10 3.2.2 Balneotherapy in Alpine healing waters 12 3.2.3 Alpine water – Blue space 20 3.2.4 Alpine creeks for Kneipp hydrotherapy 26 3.2.5 Waterfalls 30 3.2.6 Alpine mountain hiking 32 3.2.7 Climbing / Outdoor bouldering 41 3.2.8 Forest therapy 46 3.2.9 Protected areas & biodiversity 51 3.2.10 Alpine Farming and Alpine pastures - Environmental microbes 56 3.2.11 High altitude 62 3.2.12 Moderate altitude 63 3.2.13 Apitherapy 71 3.2.14 Honey 74 3.2.15 Alpine milk and dairy products 76 3.2.16 Plants / Phytotherapy 81 3.2.17 Winter - snow-based activities 85 3.2.18 Winter - Not snow-based activities 94 3.2.19 Radon 98 3.2.20 Speleotherapy 101 4 References 102 5 Figures 126 6 Tables 126
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1 Report context
The present synthesis report summarizes the results of work package 2 - Mapping of Alpine health resources within the ARPAF project HEALPS for the integration in the Health Tourism Assessment and Benchmarking Tool (HTAB) of the Project HEALPS2. The analysis was carried out by the Institute of Ecomedicine at the Paracelsus Medi- cal University Salzburg.
1.1 ARPAF project HEALPS
HEALPS was a project funded by the Alpine Region Preparatory Action Fund (ARPAF) and built the base for the Alpine Space Project HEALPS2.
Project Title:
HEALPS - Alpine Health Tourism – Positioning the Alpine region as globally attractive health promoting place
Project Partners:
• Innovation and Technology Transfer Salzburg (AT, Lead)
• Foundation Cluster Technologies For Living Environments (IT)
• University of Applied Sciences Chur (CH)
Funding:
The project is co-financed by the European Union (Alpine Region Preparatory Action Funds - ARPAF)
Start and closure dates:
January 2018 to June 2019
Project Outline:
Outdoor recreation in natural environments is becoming an important aspect of healthy living and a remedy against the deficiencies of urban life separated from na- ture. With its exceptional nature, cultural heritage, healthy climate and long tourism tradition, the Alpine region possesses significant prerequisites to benefit from this trend. However, to date there is no awareness of the unique health-promoting po- tential of the Alpine region. Major reasons for this lack of awareness are insufficient visibility and knowledge of health-promoting Alpine assets.
In contrast to the current, fragmented approaches towards the promotion of Alpine assets, the project HEALPS aims to develop a common basis for the positioning of the Alpine region as an attractive health-promoting place through data compilation,
page 3 of 126 Healing Alps: Tourism based on natural health resources as strategic innovation for the development of Alpine regions ASP815 generation and the visualisation of unique Alpine assets related to health. The project incorporates four different perspectives: Alpine resources, customers and providers as major stakeholders, education and technology.
This approach addresses EUSALP’s strategy of a better utilisation of Alpine-specific resources and creates a basis for the development of Alpine health tourism value chains to drive job creation and growth in remote Alpine areas. In this way, it coun- teracts depopulation in these areas through new business opportunities and posi- tions the Alpine region as healing environment for tourists and as an attractive envi- ronment for working and residing. The project covers six work packages (see Figure 1)
The present report summarizes the medical evidence regarding unique Alpine assets as a basis for evidence-based health tourism development that can be integrated in hands-on tools within the Alpine Space Project HEALPS2.
Figure 1: HEALPS work packages
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1.2 Alpine Space Project HEALPS 2
Tourism is a major engine for job creation and a driving force for economic growth and development in the Alpine programme area. Yet alpine tourism is currently ex- periencing challenges such as climate change and is often only focussed on specific regions. Global trends such as a thirst for nature-based experiences and increased health consciousness hold considerable opportunities for developing innovative na- ture-based health tourism experiences. To fulfil this potential, the project will provide policy-makers, regional developers, Alpine regions and SMEs access to innovation knowledge and to implementation tools.
Building on the ARPAF project HEALPS, the aim is to improve framework conditions for utilising Alpine natural health resources by developing health tourism products and service chains. Lessons learnt from existing innovative, but fragmented cases will be elevated to a transnational level. Supported by the combination of the latest re- search results with digital solutions, the nature-based health tourism approach will be tested in pilot regions and the experiences then translated into relevant tools for Alpine regional development. By engaging quadruple helix stakeholders, cross ferti- lisation between tourism, health and other relevant sectors and co-learning is stim- ulated at transnational level. This shared knowledge at various scales facilitates framework conditions for value generation based on location-bound Alpine assets.
Recommendations for different policy levels as well as guidelines & implementation toolkits for product and service chain development reflect the purpose of a broad implementation of hands-on knowledge for the stimulation of SME- and destination driven innovation. Two international conferences on Alpine health tourism will allow transnational & transversal knowledge transfer from academia to regions and SMEs. Thus, the project contributes to the positioning of the Alpine Space as globally at- tractive health promoting place.
HEALPS2 lasts from October 2019 to June 2022 and is co-financed by the European Regional Development Fund through the Interreg Alpine Space programme (Total budget: 2.169.952,65€ - ERDF grant: 1.844.459,74€).
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2 Identification of Alpine natural health resources
20 Alpine health resources relevant for the development of Alpine health tourism were identified and are shown in Figure 2.
Figure 2: Identified Alpine natural health resources
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3 Characterization of Alpine natural health Resources: Medical Evidence and Checklist for Health Tourism Development
3.1 Methodological Approach
The 20 identified resources were characterized regarding their impact on human health and well-being using an indication-based approach. The research was con- ducted using the biomedical database PubMed (NCBI, 2019). A database was created and systematically analyzed using an indication-based approach (see Figure 3and Figure 4).
Each identified Alpine resource was characterized regarding its potential health ef- fects based on available published data. The evidence level of each resource regard- ing specific indications was visualized by use of the Evidence Levels of the Agency for Health Care Policy and Research (AHCPR, see Table 1). In this way, also research gaps were identified.
Figure 3: Extract from the HEALPS database
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Figure 4: Indication-based approach to the medical-scientific characterization of Alpine resources
Evidence levels of Agency for Health Care Policy and Research (AHCPR)
Level Type of scientific evidence
Scientific evidence obtained from meta-analyses of randomized clini- Ia cal trials.
Ib Scientific evidence obtained from at least one randomized clinical trial.
Scientific evidence obtained from at least one well-designed, non-ran- IIa domized prospective study.
Scientific evidence obtained from at least one well-designed, quasi-ex- IIb perimental study.
Scientific evidence obtained from well-designed observational studies, III such as comparative studies, correlation study or case-control studies.
Scientific evidence obtained from documents or opinions of expert IV committees and/or clinical experience of renowned opinion leaders.
Table 1: AHCPR Evidence levels
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Additionally, the health tourism potential was estimated and described, if data was available. These results can be combined with the results of the questionnaire in WP 3 to finetune estimations of health tourism potential from the users’ point of view.
The medical-scientific characterization of Alpine assets (A.2.2) was integrated in the Checklist (A.2.3) and described in the following chapter.
The structure of the checklist depends on the respective resource and available data. The components of the checklist are shown in Table 2.
Checklist content:
✓ Background / Description of each identified resource in an Alpine context described for ✓ Assignation of indications to the resources all resources
✓ Evidence level of resources
✓ Research Gaps
✓ Tourism and medical infrastructure (no statements are possible, if e.g. evidence is too low)
✓ Necessary education & knowledge level description This mostly refers to the evidence of the respective re- depending on source and must be adapted to a regional/national con- resource and text available data
✓ Health Tourism Potential
✓ Cross-sectorial potential
✓ Measurement methods of health outcome
Table 2: Content of checklist for the identification of health-related p/s/a
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3.2 Medical-scientific characterization & Checklist
3.2.1 Air ions
Background
Ions are formed from originally neutral particles that have been positively or nega- tively charged by ionization. These charged particles are very small, have a high mo- bility and can be spread quickly by the wind. Due to the electrical charge, these par- ticles tend to form clusters and to combine with larger particles and aerosols in the air. The cleaner the ambient air, the longer the ions are present as small ions, floating in the air to be deeply inhaled by breathing. High levels of air pollution quickly lead to the formation of larger ions with less positive health effects, since they sink to the ground more quickly and can also be inhaled less deeply.
In comparison with green areas and forests, where the concentration is about 700 to 2000 ions/cm³, in cities with 100 to 800 ions/cm³ the concentration of negative air ions is significantly lower, because plants are important producers of negative ions. The ions are formed during photosynthesis: the more intense the light source, the more negative air ions are formed. The number of negatively charged particles there- fore increases with increasing height, because solar radiation becomes more intense. The concentration of negative air ions is highest in natural environments that host a water source, such as a river or waterfalls. The air ions are created by the unbridled force of flowing water, breaking waves and especially by the force of falling water, as is the case with waterfalls, the main producers of negative ions (Kolarž et al., 2012).
Medical Evidence
(Alexander, Bailey, Perez, Mitchell, & Su, 2013)
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(Perez, Alexander, & Bailey, 2012)
Conclusion
A range of single studies have suggested that negative air ions have multiple health benefits on humans (Jiang, Ma, & Ramachandran, 2018). They obviously have an in- fluence on human health and well-being and play a role in physiological mechanisms. There are some internationally published scientific papers and studies that have in- vestigated the effects of negative ions on various indications. A positive health effect of negatively charged air ions seems to be apparent regarding immunological, phys- iological and psychological aspects. Although, some of these results need to be fur- ther verified in high quality studies.
In combination with water aerosol from e.g. waterfalls they are likely to induce an immune-modulatory effect (see also 3.2.5 Waterfalls) .
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3.2.2 Balneotherapy in Alpine healing waters
Background
It is generally accepted that balneotherapy is an effective treatment in various dis- eases. Balneotherapy - in a strictly sense - is defined as the use of baths containing thermal mineral waters from natural springs at a temperature of at least 20°C and with a mineral content of at least 1 g ⁄ l (Falagas, Zarkadoulia, & Rafailidis, 2009). It is more common that the temperature of the thermal water is about 34 degrees. Bal- neotherapy has been used since ancient times in the treatment of various diseases and so it is today.
There is no international definition of balneotherapy in a broader sense and its treat- ment methods included. It can be mineral baths, Sulphur baths, sole baths, radon- carbon dioxide baths or dead sea salt. Spa therapy additionally to balneotherapy em- ploys various modalities such as physiotherapy, and even the change in environment and lifestyle per se may contribute to the changes seen in patient outcome meas- urements, i.e. the therapeutic result may not be attributed to the balneotherapy alone (Falagas et al., 2009). As the composition of the mineral waters differs in its content in cations and anions, it is difficult to assess the specific therapeutic compo- nent.
Medical Evidence
There are many balneotherapeutic publications with good evidence level, though it was long time considered as an alternative treatment with little evidence (Ammer, 2010). There are randomized controlled trials and even meta-analyses on the effects of balneo-/ spa-/ hydrotherapy with specific indications. The main limitation of get- ting an evidence overview is that the patient population, the balneotherapy proto- col/characteristics of the control group, and the outcome definitions are not the same across the studies even in each specific diagnosis (Morer, Roques, Françon, Forestier, & Maraver, 2017). There is a strong need for high quality studies, specifically double-blind trials, calculations of sample size (enough patients included in the study), standardized protocols and appropriate outcome measures.
Most of the existing meta-analyses address the effectiveness of balneo- and hydro- therapeutic treatments and not the effects of the specific local remedy (Ammer, 2010). The most common investigated indications for balneotherapy (meta-analysis of Falagas et al., 2009) are rheumatic diseases. Half of the studies showed a clear reduction in pain after balneotherapy in patients with rheumatism or low back pain in comparison to the control group, the other studies were indifferent regarding pain control.
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Alpine-specific Medical Evidence
The specific evidence for alpine balneotherapy is given by studies on balneothera- peutic treatments with waters that have their origins in the Alps.
(Falagas et al., 2009)
(Pittler, Karagülle, Karagülle, & Ernst, 2006)
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(Prossegger et al., 2019)
(Huber et al., 2019)
(Matzer, Nagele, Bahadori, Dam, & Fazekas, 2014)
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(Cozzi et al., 2018)
(Fortunati, Fioravanti, Seri, Cinelli, & Tenti, 2016)
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(Françon & Forestier, 2009)
(Karagülle & Karagülle, 2015)
(Kaya, Kaplan, Çarli, & Güzelkücük, 2015)
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(Matz, Orion, & Wolf, 2003)
(Morer et al., 2017)
(Santos, Cantista, & Vasconcelos, 2016)
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(Verhagen et al., 2007)
(Verhagen et al., 2015)
(Antonelli & Donelli, 2018)
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Potential health tourism indications
• Rheumatological diseases • Chronic low back pain • Osteoarthritis • Rheumatoid arthritis • Fibromyalgia • Hand Osteoarthritis • Knee Osteoarthritis • Quality of Life • Well-being • Burnout
Tourism and Medical Infrastructure
• Location-bound healing water
• Corresponding infrastructure for tourism experiences
• Specialized therapeutic services
Conclusion
The available data suggest that balneotherapy may be truly associated with improve- ment in several rheumatological diseases. However, existing research is not suffi- ciently strong to draw firm conclusions (Falagas et al., 2009). For the use of Alpine balneotherapy in health tourism, it is necessary to examine each Alpine healing water regarding its effects on specific indications and to take into account experiences from successful product development (Steckenbauer, Weisböck-Erdheim, Tischler, Pichler, & Hartl, 2019).
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3.2.3 Alpine water – Blue space
Background
The Alps serve as 'water towers' and freshwater supply for large parts of Europe. Al- pine water resources appear in different forms like creeks, glaciers, lakes, groundwa- ter bodies, wetland and soil. The major rivers Rhine, Po and Rhone have their head- waters in the mountains and provide freshwater via river systems to lower-lying ar- eas. The global warming will bring changes in precipitation regimes, snow cover pat- terns and glacier storage will influence the water availability (European Environment Agency, 2016).
Water is one of the most important physical and aesthetic landscape elements. Ever since, people were attracted by rivers, lakes and the sea. Most recent scientific re- search has focused on the interactions of water in environmental toxicology and mi- crobiology, but not on human well-being. Völker und Kistemann (2011) provide a sys- tematic, qualitative meta-analysis of studies relevant to this topic.
What impact do aquatic environments have on people’s health? While the health benefits of green space are quite well explored (Kaplan & Kaplan, 1989; R. S. Ulrich, 1984; Roger S Ulrich, 2006), little analysis has been made of "blue space" and even less on “Alpine” blue space. Blue space occasionally has been issued in public debate so far when risks are considered, eg. drowning, microbial contamination. However, staying in blue space environment can promote health and well-being. The evidence is still insufficient as far as underlying mechanisms are concerned. This is where the BlueHealth project comes in, aiming to highlight the benefits of stays in Blue Space for health and well-being, and to increase them in urban settings (Grellier et al., 2017). A UK survey among adults found that the characteristics of green space, namely so- cial interaction and psychological benefits, also apply to blue space. The socioeco- nomic status of respondents determined the frequency and location of the visits. These results show how enriching the stay of people in a natural environment is (de Bell, Graham, Jarvis, & White, 2017)
Medical Evidence
Most of the studies show a weak level of evidence. There are no intervention studies on Alpine blue space so far. Even though, there is an increasing number of non-ana- lytical studies dealing with possible benefits of blue space such as lakes and rivers on human health and well-being. Although, systematic reviews and meta-analyses are still missing. Gascon et al. (2017) reviewed 35 studies focusing on stays in blue spaces outside residential buildings. The results indicate a positive correlation between a longer stay in blue space and mental health, well-being and the level of physical ac- tivity. In summary, it should be noted that the heterogeneity of existing studies, dif- ferent measurement parameters and result sizes make synthesis difficult. Research
page 20 of 126 Healing Alps: Tourism based on natural health resources as strategic innovation for the development of Alpine regions ASP815 in several countries is needed to better understand the mechanisms of blue space, health and well-being (Gascon, Zijlema, Vert, White, & Nieuwenhuijsen, 2017).
The results of a cross-sectional study among adults in Wellington, New Zealand, sug- gest that increased visibility of nature (green space and blue space) is associated with lower mental stress (K10 scores). Further research is needed to verify that increased visibility of Blue Space also promotes mental well-being in other cities (Nutsford, Pearson, Kingham, & Reitsma, 2016)
Most studies relate to the visual aspects of nature experiences. But people are multi- sensory, and it seems likely that many benefits are achieved through the non-visual senses. The study by Franco, Shanahan & Fuller (2017) examines the effect of blue space through sound, smell, taste, touch. Beyond the five senses, there is evidence for other non-visual nature experience paths. These include the ingestion or inhala- tion of phytoncides, negative air ions and microbes. Non-visual experiences of nature experiences are potentially important, the evidence base is relatively weak, and therefore more exploration of these sensory and non-sensory pathways seems nec- essary (Franco, Shanahan, & Fuller, 2017).
Foley & Kistemann (2015) already postulated the idea of the "healthy blue space" as a further development of research on therapeutic landscapes. He defines them as "healthy places and spaces where water is at the center of a series of environments with identifiable potential for the promotion of human well-being". Based on six studies it is shown how mixed blue space can be beneficial to health. Further studies are needed on various forms of Blue Space (Foley & Kistemann, 2015).
Studies indicate that visual impressions of a natural environment compared to an ur- ban environment facilitate recovery from mental stress. Alvarsson, Wien & Nielsson (2010) examined whether auditory stimuli from nature show similar effects. After a demanding math task 40 people were played either sounds from nature or from a noisy environment. By means of skin conductance the sympathetic activity was de- termined, with the heart rate variability the activity of the parasympathetic nervous system was assessed. Although HRV showed no effects, measurements of skin con- ductance indicate that sounds from a natural environment promote recovery of sym- pathetic activity (Alvarsson, Wiens, & Nilsson, 2010).
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(Grellier et al., 2017)
(Franco et al., 2017)
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(Gascon et al., 2017)
(Foley & Kistemann, 2015)
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(Völker & Kistemann, 2011)
(Alvarsson et al., 2010)
(de Bell et al., 2017)
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(Nutsford et al., 2016)
(Bundi, 2010)
Potential Health Tourism Indications
- Mental health - Well-being - Stress recovery - Illness recovery - Recreation opportunities
Conclusion
The water resources of the mountains are of vital importance to society and the eco- system. The increasing demand for water and the effects of climate change are lead- ing more and more to water use conflicts. Overcoming these conflicts and maintain- ing the ecosystem at the same time are major challenges (Bundi, 2010). Alpine desti- nations can use their various forms of blue space to develop evidence-based health tourism products and to integrate them into economic value chains (vgl. Stecken- bauer, Tischler, Hartl, & Pichler, 2017). According to the authors the healing potential as well as the resulting health tourism potential are still underestimated and should be focus of further research.
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3.2.4 Alpine creeks for Kneipp hydrotherapy
Background
Kneipp water applications belong to the commonly used therapies in the field of na- turopathy. The list of indications for Kneipp hydrotherapy is long, but the scientific evidence is hardly explored by clinical studies. In many cases the application is based on experiences (Uehleke, 2015). Core elements of Kneipp’s hydrotherapeutic treat- ments are water treading, hot and cold half-baths and full baths, contrast baths, steaming treatments, wraps and compresses, and, most important, the brief cold gush to different body parts (Locher & Pforr, 2014). Moderately intense daily physical activities are also part of Kneipp’s hydrotherapy.
Medical Evidence
There is insufficient evidence from clinical studies on the efficacy of Kneipp hydro- therapy treatments. But as therapeutic add-on option for different diseases, hydro- therapy according to Kneipp has become more and more a topic of scientific re- search. Positive treatment successes were found for Kneipp hydrotherapy as an add- on therapy for example in the concomitant treatment of dementia. There is good evidence (evidence level Ib) that cold water applied locally to face and neck region is able to provoke significant improvements of cognitive abilities (Doering et al., 2001) or chronic obstructive pulmonary disease (Goedsche, Förster, Kroegel, & Uhlemann, 2007). Hack et al. (2015) report that Kneipp therapies can provide effective short-term relief of disease- and therapy-related side effects. These therapies can help to ensure that treatments are tolerated better, improving compliance and allowing treatment to be completed according to medical guidelines.
Hydrotherapy in general shows therapeutic benefits concerning balance, increasing mobility and quality of life for people with movement disorders (Rocha, McCLEL- LAND, & Morris, 2015).
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(Rocha et al., 2015)
(Doering et al., 2001)
(Eckert & Anheyer, 2018)
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(Schencking, Wilm, & Redaelli, 2013)
(Locher & Pforr, 2014)
(Hack et al., 2015)
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(Goedsche et al., 2007)
Potential Health Tourism Indications
- Improvement of Quality of life - Stress Reduction - Well-being - Movement disorders - Respiratory Infections - Dementia
Tourism/regional prerequisites
Creating seasonal concepts with which alpine creeks can be staged, always with a view to sustainability and compatibility with values. Find suitable partnerships, en- sure profitability. Offer health experiences based on cold water. Focus on evidence- based health tourism products.
Conclusion
There are indications that Kneipp hydrotherapy can be a useful supplementary treat- ment for people with different disease patterns. However, it needs clinical trials that compare e.g. therapies of varying duration and frequency to clarify the associated risks and benefits for each indication (Rocha et al., 2015).
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3.2.5 Waterfalls
European mountain regions host numerous alpine waterfalls, which produce inhala- ble, negatively charged nano-water particles known as „Lenard ions” (see also chap- ter 3.2.1). Negative air ions nearby waterfalls, so called „ionosols“, are generated by aerosolization of water droplets at an obstacle, aqueous surface or by aerodynamic break-up during free fall. After breaking up, smaller fragments carry negative charge and remain in the air for some time carried by air stream. Their diameter is between 1.5–10 nm, whereby 2 nm sized negative ions were most abundant. Lifetime of iono- sols is long enough so that they can be inhaled. Remaining bigger fragments are pos- itive and precipitate to the ground (Kolarž et al., 2012; Laakso et al., 2007). This air- borne nano-aeorosol is assumed to trigger a variety of biological effects, e.g. mild activation of the immune system, stabilizing of the autonomous nervous system and improving blood flow (Krueger, 1985; Palti, De Nour, & Abrahamov, 1966; Takahashi et al., 2008). In a mouse model, water-generated negative ions have been shown to enhance cytotoxic activity of natural killer cells (Yamada et al., 2006).
This specific environment of a waterfall provides beneficial effects for prophylactic and therapeutic stress management when combined with high-altitude climate ther- apy and physical activity (mountain hiking) (Grafetstätter et al., 2017). Another ran- domized, clinical trial demonstrates positive immunomodulating effects of this wa- terfall-microclimate. A stay in close proximity to the impact zone of an alpine water- fall (the Krimmler waterfalls), has proven beneficial effects for the treatment of aller- gic asthma and is even listed as an approved natural remedy (Gaisberger et al., 2012).
Medical Evidence
(Gaisberger et al., 2012)
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(Grafetstätter et al., 2017)
Conclusion
Numerous curing and healing effects are ascribed to waterfalls in ancient traditions and folk wisdom in many regions of the world. There is evidence for an added health benefit due to exposure to a waterfall environment in combination with mountain hiking and a stay in moderate altitude. Furthermore, the medical evidence points to an influence of the waterfall ionosols on complex “psychoneuroimmunological” reg- ulatory circuits and balancing immunomodulating mechanisms. Alpine waterfalls portray a simple to implement and cost-effective health tourism product base for the treatment of stress-related symptoms, allergies and airway diseases.
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3.2.6 Alpine mountain hiking
Background
In the age of industrialization holidays primarily focused on regeneration, rest and recreation. The structural shift towards a service-oriented society has led to a change in holiday interests in the Western world. Although rest and recreation are still im- portant to people during their holidays, the range of physical activities carried out while on holiday has increased considerably since the end of the 1990s. Especially hiking is becoming increasingly popular and represents an important travel motive (Dreyer & Menzel, 2016).
There is no precise definition of mountain hiking in the scientific literature. Following the Tyrol Declaration on Best Practice in Mountain Sports it can be defined as walking in a mountainous environment predominantly on marked trails and paths. From a physiological point of view, mountain hiking can generally be characterized as a long- lasting activity including large muscle mass with predominantly moderate intensity which is considered beneficial for health (Martin Faulhaber et al., 2017).
The main reasons for hiking are experiencing nature, fresh air, the beauty of nature and landscape, fauna, and flora (BMWI, 2010). Another aspect that is becoming in- creasingly important is health as a motive for hiking holidays and the scientific evi- dence of the positive effects of hiking on health and well-being is constantly growing.
One of the first approaches to investigate the health effects of alpine mountain hiking were the “Austrian Moderate Altitude Studies” (AMAS) that were conducted in Aus- tria. AMAS I (2000) focused on the indication of the metabolic syndrome, a combi- nation of overweight, disturbed blood sugar and blood fat metabolism as well as el- evated blood pressure, which are massive cardiovascular risk factors, whereas AMAS II (2006) focused on persons with high stress levels. The studies proved that an active sojourn (a combination of hiking and active/passive regeneration) at Alpine moder- ate altitudes (1,500 - 2,500 m) under the guidance of professional coaches has posi- tive effects in persons with metabolic syndrome as well as in a clientele suffering from stress (Humpeler & Schobersberger, 2008; Neumayr et al., 2014; Wolfgang Scho- bersberger et al., 2003).
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Mountain hiking and healthy aging
Healthy aging and physical activity go hand in hand and efficient interventions to preserve functional abilities to prolong disability-free life expectancy are needed.
Most of these interventions are indoor training programs. However, mountain hiking is a very popular leisure time activity among older people. More than 6 million people older than 60 years undertake mountain activities in the Alps every year, but moun- taineering demands a relatively high level of physical fitness. Aging is typically asso- ciated with declining fitness, but this decline is not the result of aging solely, it is mostly the price of physical inactivity (Prossegger, 2019).
During mountain hiking, mountaineers are confronted with often rapidly changing environmental conditions like slope of the path, stony or narrower passages, altitude, weather conditions, ascending and descanting sections. These constantly changing conditions require constant proprioceptive feedback, thus promote the diversifica- tion of gait pattern and balance responses (James, 2014)
Mountain hiking could therefore be an effective training for older people, addressing both aerobic capacity, strength and balance.
Balneotherapy could be a useful tool to improve regeneration after mountain hiking. The beneficial effects of balneotherapy are widely used to treat musculoskeletal dis- eases, to improve immunity and to relieve pain (Prossegger, 2019). Bathing in thermal water triggers several physiological responses like vasodilation, gate control mecha- nism, elevation of beta-endorphin levels and muscle relaxation, which could posi- tively affect regeneration after exercise like e.g. mountain hiking.
The following section gives an overview of the scientific evidence regarding health effects of Alpine mountain hiking.
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Medical Evidence
(Wolfgang Schobersberger et al., 2003)
(Wolfgang Schobersberger et al., 2005)
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(Neumayr et al., 2014)
(Theiss et al., 2008)
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(Winklmayr et al., 2015)
(Niedermeier, Grafetstätter, Hartl, & Kopp, 2017)
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(Niedermeier, Einwanger, Hartl, & Kopp, 2017)
(Niedermeier, Hartl, & Kopp, 2017)
(Burtscher et al., 2001)
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(Sturm et al., 2012)
(Grafetstätter et al., 2017)
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(Prossegger et al., 2019)
(Huber et al., 2019)
Health tourism potential
Alpine mountain hiking is becoming increasingly popular. The number of tourists vis- iting altitudes above 2000 m in the Alps is estimated at about 40 million people per year (Martin Faulhaber et al., 2017). Furthermore, hiking is a so-called “lifetime sport”, as it can be practised by people of nearly all age groups. Health issues have an in- creasingly high priority for hikers. Besides being able to experience nature, the mo- tives “getting exercise” and “do something for my health” have the highest priorities for hikers and the significance of these motives increase with age (Dreyer & Menzel, 2016).
The health tourism potential for Alpine hiking can therefore be seen as very high in Alpine regions. In product development, they should ideally be combined with other
page 39 of 126 Healing Alps: Tourism based on natural health resources as strategic innovation for the development of Alpine regions ASP815 location-bound natural resources that could provide additional health benefits, such as balneotherapy or waterfalls. The additional integration of location-bound re- sources contribute to the development of a unique health tourism appeal as they are geographically specific and cannot be exported (Steckenbauer et al., 2017).
Another element for health tourism differentiation in the field of mountain hiking is the development of target group specific products. Hiking trails have different char- acteristics that can be developed for specific indications like e.g. cardiorespiratory fitness, chronic low back pain etc. Target group specific products can e.g. be devel- oped along increasing civilization diseases.
The other side of the undoubtedly positive effects of Alpine mountain hiking is the risk of accidents, emergencies, and even fatalities. Therefore, risk and protective fac- tors must be taken into account in product development. For example, physical ac- tivity on the first day at altitude is an important condition that is associated with sud- den cardiac death (SCD). Research shows that acclimatisation to moderate altitudes improves altitude tolerance and physical performance over time at altitude and may elevate the ischaemic threshold and reduce arrythmia frequency in people with un- derlying coronary artery disease (CAD). These observations suggest the protective effects of acclimatisation to altitude are likely also occurring when spending the first night closer to the altitude where hiking activities on the following day will be per- formed (Martin Faulhaber et al., 2017). In this context, it becomes clear that evidence- based health tourism products should always be developed in a constant dialogue between tourism and medical-scientific experts.
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3.2.7 Climbing / Outdoor bouldering
Background
Rock climbing is a popular leisure time activity among all age groups. Several disci- plines can be distinguished, including traditional climbing, sports climbing and boul- dering. In traditional rock climbing, as well as in sports climbing, the climber is at- tached to a rope, either clipping the rope into bolts from the bottom up (lead climb- ing) or the rope is already anchored at the top (top rope climbing). In contrast, in bouldering the climber is not secured by a rope. As the so-called boulder problems are usually located low to the ground, crash mats are used instead of ropes. Rock climbing and bouldering can be practiced indoors as well as outdoors. The Alpine mountains offer an infinite number of climbing and bouldering routs in varying skills levels. In addition, many indoor climbing facilities and climbing parks are available. For describing the difficulty of a climb, several grading systems have been developed. Most common in the Alps are the French and UIAA grading systems.
Medical Evidence
Therapeutic climbing is a new approach which has been adapted from artificial rock- climbing motions. It does not necessarily involve climbing entire routes as done in traditional climbing but may only involve specific exercises performed on a climbing wall. Therapeutic climbing is currently used for orthopedic, neurological and psycho- logical disease. A meta-analysis from 2010 states that the evidence for the effective- ness of therapeutic climbing is limited and at high risk of bias and therefore the ef- fects of therapeutic climbing are still unclear (Buechter & Fechtelpeter, 2011).
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Climbing in health prevention
(Heitkamp, Wörner, & Horstmann, 2005; Muehlbauer, Stuerchler, & Granacher, 2012)
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Therapeutic climbing for cerebral palsy
Cerebral palsy (CP) is a neurodevelopmental disorder resulting from an injury to the developing brain. It is the most common form of childhood disability with prevalence rates of between 1.5 and 3.8 per 1000 births reported worldwide. The primary impair- ments associated with CP include reduced muscle strength and reduced cardi- orespiratory fitness, resulting in difficulties performing activities such as dressing or walking.
(Böhm, Rammelmayr, & Döderlein, 2015; Schram Christensen, Jensen, Voigt, Nielsen, & Lo- rentzen, 2017)
Therapeutic climbing for multiple sclerosis
Multiple sclerosis (MS) is one of the most frequent organ specific diseases of the cen- tral nervous system. The diseases spectrum of MS is ranging from no symptoms to severe disabilities. Climbing offers a lot of possibilities to be adapted for individual
page 43 of 126 Healing Alps: Tourism based on natural health resources as strategic innovation for the development of Alpine regions ASP815 needs. Today there is only little research about how therapeutic climbing might in- fluence MS. To determine the therapeutic impact of a climbing intervention on MS, a multitude of further research is required (Steimer & Weissert, 2017).
(Velikonja, Curić, Ozura, & Jazbec, 2010)
Therapeutic climbing for back pain
(S.-H. Kim & Seo, 2015; Schinhan et al., 2016)
Therapeutic climbing for psychological diseases
According to a recent review, the effectiveness of climbing therapy on psychological outcomes remains unclear. There is a need for further studies in children and adults on psychological outcomes through climbing therapy, especially in comparison with
page 44 of 126 Healing Alps: Tourism based on natural health resources as strategic innovation for the development of Alpine regions ASP815 aerobic activity interventions (Frühauf, Sevecke, & Kopp, 2018). Bouldering psycho- therapy (BPT) is another type of therapeutic climbing, which combines psychothera- peutic elements with physical activity.
(Stelzer et al., 2018)
Tourism/regional prerequisites
Climbing or boulder facilities and highly trained personal (climbing instructor, physi- otherapists, psychologist) are required for climbing therapy.
Measurement methods:
• HRQOL- Questionnaires (SF-36) • VAS for pain
Conclusion
Further research is required for the described indications. Only long-term interven- tions were examined in the existing studies. This is limiting the implementation in health tourism. Furthermore, highly trained staff is needed and no evidence about short-term interventions (e.g. 1-2 weeks) is available.
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3.2.8 Forest therapy
Background
In recent years, there has been considerable and increasing attention in using the forest environment as a place for recreation and health promotion. This trend derives from Japan, where it is called shinrin-yoku, which is a term that means “taking in the forest atmosphere through all of our senses” or simpler “forest bathing”. Since the development of the concept during the 1980s, considerable scientific research on its health effects and the mechanisms behind the healing effects was conducted (C. Song, Ikei, & Miyazaki, 2016). The first studies were conducted at the Japanese island Yakushima (shima = island in Japanese). Yakushima includes a ≈19,000 ha area as a biosphere reserve. The island is located at a biogeographic boundary between trop- ical and temperate regions and contains a remarkably rich variety of flora: There are evergreen broadleaf forests, conifer, 2000-year-old cedar trees, and nearly 2000 dif- ferent plant species (Craig, Logan, & Prescott, 2016). Most other forest study sites have similar characteristics. This is important to mention when it comes to discuss the transferability of study results from tropical/south Asian forests to European resp. Alpine forests.
Studies1 report health benefits including impacts on humans’ immune system, boost- ing natural killer cells and anticancer proteins, reduced stress, improved mood, sleep and well-being, reduced blood pressure, accelerated recovery from illness and in- creased ability to concentrate (a.o. Kamioka et al., 2012; J. Lee et al., 2014; Li, 2010; Li et al., 2016; Tsunetsugu, Park, & Miyazaki, 2010; Tsunetsugu, Park, Lee, Kagawa, & Miyazaki, 2011).
Based on these results, more than 50 Forest Therapy Trails were developed in Japan with millions of annual visitors and forest therapy has become a cornerstone of pre- ventive health care and healing in Japanese medicine. Also in other Asian countries like China and South Korea, forest therapy has become very popular and the trend is now also emerging in Europe (Association of Nature and Forest Therapy Guides and Programs, 2019).
Forests in the Alpine region
Alpine forests represent a distinguishing element of the Alpine region. More than 40 percent of the Alpine area is covered by forests with a total wood volume of 2,000 million m3. In recent years, there has been a significant expansion of the forest cover,
1 although often of poor methodological quality, see chapter “Medical evidence”
page 46 of 126 Healing Alps: Tourism based on natural health resources as strategic innovation for the development of Alpine regions ASP815 particularly in the southern and western part of the Alpine region, due to abandon- ment of marginal agricultural areas (meadows and pastures). Alpine forests carry out many important ecoservices: soil conservation, protection against natural disasters, renewable sources of raw materials, energy sources and employment opportunities, mitigation of climate change, ecosystem conservation and protection of Alpine land- scapes (Alpine Convention, 2018; Hermann, 2017).
Furthermore, forests are an important area for recreational activities and play a key role in tourism, as they shape the landscape and lot of hiking trails etc. lead through Alpine forests. Considering the emerging global trend of forest therapy and the rich occurrence of forests in the Alpine area, one might think that forests and their pos- tulated health effects are a good base for the development of Alpine health tourism products. However, a closer look to the scientific literature on forest therapy reveals several gaps and shortcomings, especially regarding research methodology and transferability of results.
Medical Evidence
There are more than 150 publications on forest therapy (including keywords “shinrin- yoku”, “forest therapy” and “forest bath”) listed in PubMed (NCBI, 2019). Despite this large body of literature, the evidence base for health benefits attributable to forest therapy is rather low due to methodological weaknesses. Oh and colleagues (2017) conducted a systematic review on forest therapy, where only six randomized con- trolled trials (RCT, highest evidence regarding single intervention studies) met the inclusion criteria. These criteria were based on the assessment of methodological quality according to the Cochrane risk of bias (ROB) tool. The review found that the included six RCTs reported promising therapeutic benefits of forest exposure on sev- eral physical and psychological conditions including hypertension, cardiac and pul- monary function, immune function, inflammation, oxidative stress, stress, stress hor- mone, anxiety and depression, and emotional response; although outcomes of anxi- ety and depression had mixed results and some inflammatory biomarkers showed null results. The review concludes that there is a consistent trend in a broad range of health outcomes, suggesting potential for forest bathing. Although, the authors state that the included studies had a high risk of bias. Due to this lack of high-quality stud- ies there is no convincing evidence of the benefits of forest therapy. Furthermore, none of these studies were registered at the international trial registry (ISRCTN reg- istry).
Within the two years since the publication of Oh and colleagues’ review, only four further randomized controlled trials were published (also not registered at the ISRCTN). Two of them were conducted in China and showed beneficial effects on patients with chronic heart failure (Mao et al., 2018, 2017). The other two studies were conducted in Denmark and Sweden and could not show any difference between the
page 47 of 126 Healing Alps: Tourism based on natural health resources as strategic innovation for the development of Alpine regions ASP815 forest therapy and the control group regarding physiological parameters (Dolling, Nilsson, & Lundell, 2017; Stigsdotter, Corazon, Sidenius, Kristiansen, & Grahn, 2017).
Besides the lack of methodological quality, there are further limitations on the trans- ferability of study results to Alpine forests:
• Research suggests that many measured health effects are attributed to phy- toncides, which is a generalized term for natural chemicals released by plants into the environment. It is theorized that these chemicals could influence stress physiology and immunology through inhalation. Most forest therapy studies were conducted in tropical primeval forests (mostly Japanese, Korean, and Chinese) with a high biodiversity (Craig et al., 2016). These forests are to- tally different from typical Alpine forests. Almost all Alpine forests are semi- natural as defined by Forest Europe, with a significant presence of large trees and deadwood. There are almost no truly primary forests and plantations (Hermann, 2017). Thus, also the their phytoncide composition is totally differ- ent. The measured effects can therefore not be transferred to Alpine forests.
• In most studies, the control group stayed in Asian megacities like Tokyo with high air and noise pollution. The measured health benefits can therefore also be attributed to the absence of these factors. Furthermore, these cities are not comparable to typical European/Alpine cities. This hypothesis is sup- ported by the study of
• Additionally, most studies involving forest therapy experiments have reported the various effects on male Asian subjects (Chorong Song, Ikei, Kagawa, & Miyazaki, 2019), which is a further limitation on transferability.
To date, there are only three randomized controlled clinical trials that were con- ducted in Europe:
(Dolling et al., 2017)
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(Sonntag-Öström et al., 2015)
(Stigsdotter et al., 2017)
Alpine context
No single intervention study could be found that investigates the health effects of activities in Alpine forests.
Conclusion In conclusion, strong evidence of the benefits of forest environment on health and well-being has yet to be confirmed. The findings of previous research support the premise that exposure to forest environments may provide health benefits. Alt- hough, the evidence is insufficient due to methodological design flaws (Oh et al., 2017). Future investigations are necessary to validate forest specific health effects, especially for Alpine forests.
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Health tourism potential Considering the rich occurrence of forests in the Alpine region and the emerging trend towards nature-based recreation, forests may be considered as an important resource with a high health tourism potential. However, based on current data, no scientifically founded statement can be made about the specific health effects of Alpine forests. Therefore, there is a strong need for future research with a high study quality.
Based on the characteristics and limitations of previous studies, several recommen- dations for future research can be given:
• Evaluation of both short-term intervention and long-term intervention dura- tion is recommended, with multiple follow-ups in the post intervention phase (Oh et al., 2017).
• The dose-response relationship should be examined by varying length, fre- quency and intensity of intervention, as measured by a physical activity inten- sity scale (Oh et al., 2017)
• Furthermore, an adequate sample size is recommended to detect statistical and clinical significance. Therefore, future studies should include power cal- culations for sample size selection (Oh et al., 2017).
• Mixed methods approaches: Both quantitative and qualitative approaches should be used as outcome measurements that capture the complexity of the forest environment effect (Oh et al., 2017).
• Disease-specific biomarkers could be used to provide information on the physiological and psychological effects of forest intervention (Oh et al., 2017). This is especially important for indication-based health tourism development.
• Researchers should not only present the efficacy data, but also any adverse events or harmful phenomena like e.g. pollen for people with allergies in spe- cific seasons (Kamioka et al., 2012)
• Papers should be based on CONSORT (Consolidated Standards of Reporting Trials) and registered at the ISRCTN registry.
• Integration of a health economics perspective: Cost-benefit analysis should be conducted to support a possible reimbursement or co-payments by health insurances
• In an Alpine context, it is necessary to investigate different types of forests in different altitudes, seasons and climate zones. Furthermore, co-factors like lakes, rivers etc. in forests should be considered.
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3.2.9 Protected areas & biodiversity
Background
The Alps are among the richest regions of Europe regarding the variety of landscapes and plant and animal species. As the loss or destruction of habitats is the most direct threat to biodiversity, protected areas are crucial to counter the continuing loss of ecosystems and species (European Environment Agency, 2016).
The Alpine regions cover more than 400 protected areas among the most important categories (see also
Figure 5: Protected Areas in the Alps; Source: (ALPARC, 2018)):
• 13 National parks
• 87 Regional/Nature parks
• 288 Nature reserves
• 13 Biosphere reserves
• 4 UNESCO World Natural Heritage sites
• 3 Geological reserves
There are also about 600 special protections listed in the Alpine region, which are often overlapping existing protected areas. All in all, more than 1000 large alpine pro- tected areas are listed. They cover about 25 % of the Alpine region (ALPARC, 2018). The Alps are thereby one of the world’s most important ecoregions in terms of con- serving global biodiversity (European Environment Agency, 2016).
According to the Convention on Biological Diversity (Article 2), biodiversity means the variability among living organisms from all sources, including inter alia, terrestrial, marine, and other aquatic ecosystems and the ecological complexes of which they are part. This variability includes diversity within species, between species, and of ecosystems. This definition reflects different levels of biodiversity including genetic diversity, species and ecosystems (World Health Organization, Convention on Bio- logical Diversity, & United Nations Environment Programme, 2015).
Closely linked to biodiversity is the environmental microbial diversity that influences the human microbiome, which is the collection of microorganisms including bacteria, archaea and fungi living in and on the bodies of humans. This is an emerging research field in medical science and holds significant health tourism potential as specific Al- pine resource. Therefore, the microbiome will be discussed as a separate resource in Chapter 0.
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Large protected areas in the Al- pine region.
• National Parks
• Nature Reserves
• Regional/Natur Parks
• Special protected areas
• UNESCO World Natural Heritage sites
• Biosphere reserves
Figure 5: Protected Areas in the Alps; Source: (ALPARC, 2018)
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Medical Evidence
Biodiversity and human health are interlinked in various ways. A large body of papers regarding the effects of protected areas on human health focuses on the provision of ecosystem services. For example, Harrison et al. (2016) showed it has been shown, that nearly two thirds of the global population relies directly on protected areas for freshwater provision. Also, protected areas play an important role in providing polli- nation services for food production or in contributing to air purification and temper- ature regulation. Another important role of protected areas is the conservation of medical plants and the numerous recreational services provided by protected areas that promote a healthy lifestyle (Terraube, Fernández-Llamazares, & Cabeza, 2017).
The most well-researched aspect of the direct link between protected areas and hu- man health is the effects on psychosocial well-being. Protective areas have a strong restorative capacity and have shown to foster recovery from mental fatigue, reducing stress levels, assisting cognitive functioning, and improving the overall psychological state (Terraube et al., 2017; I. D. Wolf, Stricker, & Hagenloh, 2015). Some studies show that these psychological benefits are higher in areas of greater biodiversity (Fuller, Irvine, Devine-Wright, Warren, & Gaston, 2007; L. J. Wolf, Zu Ermgassen, Balmford, White, & Weinstein, 2017). Furthermore, research indicates a potential beneficial and protective influence of residential areas with a high biodiversity on respiratory health (Liddicoat et al., 2018).
Linking Alpine protected areas to specific indications:
Studies that contribute to the understanding of positive health outcomes of pro- tected areas and biodiversity are mostly conducted in Australia (see e.g. Liddicoat et al., 2018; I. D. Wolf et al., 2015) or Scandinavia (see e.g. Puhakka, Pitkänen, & Siikamäki, 2017).
No intervention study could be identified that explicitly links Alpine-specific pro- tected areas to direct health outcomes. Although, based on the indirect links of pro- tected areas and biodiversity to human health and well-being, we strongly believe, that there is a huge health tourism potential. Also, protected areas play a key role in the conservation of other Alpine natural resources with medical-scientific proof such as waterfalls and can therefore be seen as “meta health resources”.
However, the research base regarding studies that address specifically the role of protected areas in supporting human health is generally low. Biodiversity-health link- ages have often been explored by looking at ecosystem service flows like for example water and energy provision but are rarely taking protected areas as a leading analyt- ical unit. Consequently, health outcomes of protected areas have been largely over- looked (Terraube et al., 2017). Therefore, there is both a strong need and potential for research programs that foster health-biodiversity linkages, especially in terms of Al- pine protected areas. To fully exploit the resulting health tourism potential, research
page 54 of 126 Healing Alps: Tourism based on natural health resources as strategic innovation for the development of Alpine regions ASP815 projects should be characterized by a strong integration of the protected area’s man- agement and the tourism industry.
Potential Health Tourism Indications:
• Nature connectedness / Nature relatedness • Recovery from stress and fatigue • Health related Quality of Life / Well-being • Fostering physical activity
Potential Measurement methods:
• Health related Quality of Life • Nature connectedness scales • Nature relatedness scales • Well-being questionnaires • Trier Inventory for Chronic Stress (TICS) • The International Physical Activity Questionnaire (IPAQ)
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3.2.10 Alpine Farming and Alpine pastures - Environmental microbes
Background The microbiome is currently a hot topic in the scientific community as well in the mainstream media. Within the period of 2012 to 2017, the number of scientific publi- cations increased by up to a factor three (Doré, Multon, Béhier, & participants of Giens XXXII, Round Table No. 2, 2017). Regarding asthma specifically, accumulating evi- dence indicates that the environmental microbiome plays a significant role in asthma development. The very low prevalence of asthma in populations highly exposed to microbial indicates its potential for disease prevention. These protective effects is most likely related to the specific microbial diversity in a farming environment, espe- cially those with livestock (Jackson, Gern, & Lemanske, 2017).
The human microbiome is defined as the collection of all microorganisms including bacteria, archaea and fungi living in and on the bodies of humans. The microbiome seems to affect virtually every bodily function. Depending on its composition, it can produce thousands of different biologically active substances, including neurotrans- mitters such as dopamine, serotonin and norepinephrine. According to the current state of science, the diversity of the microbiome seems to play the biggest role in human health. It is becoming increasingly apparent that the composition of the in- testinal microbiome beginning in utero has long-term consequences on human health and well-being. It is therefore extremely important for the maintenance of health to allow the human microbiome to have a lively exchange with microbes from the environment. However, increasing urbanization and changing lifestyles like e.g. more sedentary lifestyles reduces the spectrum of microorganisms we are exposed to: Studies show for example that people living in densely populated areas are less susceptible to microbial diversity than people living in rural neighbourhoods, which also reduces the diversity of the human microbiome. There is emerging evidence that biodiversity loss in the wider environment might lead to reduced diversity in human microbiota and these modifications were associated with a dramatic increase in in- cidence of immune-mediated diseases including metabolic, allergic and inflamma- tory diseases and most likely also neurodegenerative and psychiatric disorders (see a.o. Doré et al., 2017; Hanski, 2014; Parajuli et al., 2018; Postler & Ghosh, 2017; Prescott, Wegienka, Logan, & Katz, 2018; Saleem, 2015; Whitmee et al., 2015).
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Medical Evidence Asthma and allergies are today the most common chronic diseases in children and the leading causes of school absences, chronic medication usage, emergency de- partment visits and hospitalizations, which affect all members of the family and rep- resent a significant societal and scientific challenge (Chawes, 2016). There is strong evidence that the development of allergic sensitization can be influenced by envi- ronmental co-factors. A large body of literature (see cards below) shows that children raised on farms have much lower rates of allergies and asthma. One key reason might be that the kids breathe in air full of molecules from the cell wall of certain bacteria, called lipopolysaccharides for their fatsugar structure. Also known as endotoxins, these fragments - from dying bacteria in cow manure and fodder - cause a temporary low state of inflammation in the lungs that somehow dampens the immune system’s response to allergens (Kaiser, 2015).
The timing of the exposure to farm environmental microbes seems to be crucial. The strongest effects are observed for exposures that occurred in utero and during the first years of life (von Mutius & Vercelli, 2010). This implies a variety of options for future preventive strategies in terms of health tourism.
(Von Ehrenstein et al., 2000)
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(Riedler, Eder, Oberfeld, & Schreuer, 2000)
(Ege et al., 2011)
(Alfvén et al., 2006)
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(Horak et al., 2002)
(Schulze, Strien, Praml, Nowak, & Radon, 2007)
(Radon, Ehrenstein, Praml, & Nowak, 2004)
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(Riedler et al., 2001)
(Ege et al., 2006)
Health tourism potential:
The microbiome in early life clearly influences immune development and asthma. There is a strong evidence base, that being born and raised in a farm provides a long- lasting protection for allergies, whereby the microbial environment provided by farm
page 60 of 126 Healing Alps: Tourism based on natural health resources as strategic innovation for the development of Alpine regions ASP815 animals is crucial to induce this protective effect (Frossard et al., 2017). Also, it is be- coming increasingly apparent that the composition of the intestinal microbiome be- ginning in utero has long-term consequences on disease expression, including in- flammatory bowel disease, obesity, allergic diseases, and asthma, among others (Jackson et al., 2017).
Development opportunities:
• Holidays for pregnant women on farms and alpine pastures for the prevention of allergy and asthma
• Holidays for families with kids in the first year of life for the prevention of al- lergies and asthma
Measurement methods:
• Follow-up - Questionnaires regarding symptoms of allergy and asthma, wheezing,
Research Gaps
Although, the studies that identified the protective effect of the farming environ- ment for allergies in children are cross-sectional epidemiological studies and not ex- perimental studies. However, one promising experimental study on mice could be detected: Results show that mice bred on a farm were less prone to develop allergies than mice bred and born at the university animal facility. The authors conclude that a farming environment provides a strong, allergy protective IL-22 stimulus and gen- erates activated CD4+ T cells. In accordance with epidemiological studies, they also showed that the protective effect is dynamic, as it is mostly effective early in life (Frossard et al., 2017).
Summarizing, the medical-scientific evidence shows a great potential for the devel- opment of new health tourism products focusing on the prevention of allergies and asthmas. Alpine farms and alpine pastures could represent a valuable resource for city dwellers who are exposed to reduced microbial diversity in their everyday urban life. Current studies show, that the timing of exposure to the farm environment is crucial: The strongest effects were observed for exposures that occurred in utero and during the first year of life.
Although, to prove the protective effect, experimental studies on humans are needed.
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3.2.11 High altitude
Description
Altitude training is a popular training strategy among athletes to improve sea-level performance. Today, altitude training has become a standard training protocol in many endurance sports, to increase exercise capacity. Athletes either live or sleep in artificial or natural hypoxic conditions, to increase erythropoietin concentrations, which are thought to improve maximum oxygen uptake and thus increase exercise performance. Different types of altitude training have been developed. The intermit- tent hypoxia training (IHT) consists of brief periods of daily exposure to severe hy- poxia. Another approach, the so called living high-train low method (LHTL) involves living at high/moderate altitude in combination with training at low altitude (de Paula & Niebauer, 2012).
Medical Evidence
(Płoszczyca, Langfort, & Czuba, 2018, Lundby & Robach, 2016)
Conclusion
Although altitude training is widely used to improve exercise capacity, a clear scien- tific proof for its effectiveness is still missing. Further research is needed to explore the effects of altitude training in detail.
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3.2.12 Moderate altitude
Background
Therapies at moderate to high altitude are known to affect a variety of physiological and immunological parameters. These include neurovegetative, cardiovascular or thermoregulation mechanisms (Butykova, Kolesar, Turecekova, & Najvarova, 1973; Cepilova, Porubska, & Slamova, 1993), but also the reduction of inflammatory diseases and the induction of balancing immunomodulatory effects (Karagiannidis et al., 2006; Simon, Grotzer, Nikolaizik, Blaser, & Schoni, 1994; van Leeuwen, 1924). A stay at 1,500 to 3,000 m above sea level brings health benefits and physical activity at these mod- erate altitudes reinforces this positive effect (Burtscher et al., 2001).
In contrast to UV radiation, which increases with rising sea level and is associated with vitamin D synthesis, fine dust pollution is reduced with increasing altitude (Eu- ropean Environment Agency, 2017). Furthermore, shorter flowering phases and more extreme weathering conditions lead to a change in vegetation at higher altitudes, which in turn significantly reduces allergen concentrations compared to lower-lying natural habitats (Leuschner & Boehm, 1981).
The "thinner" air or lower air viscosity facilitates breathing and stays at medium alti- tudes lead to relaxation and stress reduction (Wolfgang Schobersberger, Leichtfried, Mueck-Weymann, & Humpeler, 2010). Physical activity at moderate sea level leads to a significant increase in haematopoietic progenitor cells, promotes erythropoiesis and thus increases the number of erythrocytes and oxygen supply (Theiss et al., 2008).
A one-week stay at 1,700 m above sea level leads to significant improvements in sugar metabolism and cardiovascular parameters such as pulse and blood pressure (Frick et al., 2006; Gunga et al., 2003; Massimo, Blank, Strasser, & Schobersberger, 2014; W. Schobersberger et al., 2000; W. Schobersberger et al., 2003).
Mechanisms underlying the immunomodulatory effect of higher altitude include the normalization of eosinophil levels, balancing of the TH2/Treg cell ratio, increase of regulatory cytokines (e.g. IL-10) and even altered immunoglobuline class-switching (Hummelshoj, Ryder, & Poulsen, 2006; Karagiannidis et al., 2006; Simon et al., 1994). Furthermore, alterations of Adrenocorticotropic hormone (ACTH) and glucocorticoid secretion indicate that conditions in moderate to high altitude affects both neuronal as well as immune circuits (Cepilova et al., 1993).
Climate therapy moderate to high altitude is also well-known as a successful alter- native medical treatment for respiratory and allergic diseases such as bronchial asthma, atopic dermatitis, psoriasis or eczema (a Porta, Barandun, & Wuthrich, 2000; Engst & Vocks, 2000; Rijssenbeek-Nouwens & Bel, 2011).
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Medical Evidence
(Edlinger et al., 2017)
(Theiss et al., 2008)
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(Karagiannidis et al., 2006)
(Frick et al., 2006)
(Gunga et al., 2003)
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(Massimo et al., 2014)
(Leuschner & Boehm, 1981)
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(Wolfgang Schobersberger et al., 2005)
(Wolfgang Schobersberger et al., 2003)
(Burtscher et al., 2001)
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(Neumayr et al., 2014)
(Rijssenbeek-Nouwens & Bel, 2011)
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(a Porta et al., 2000)
(Engst & Vocks, 2000)
Conclusion
There is a lot of scientific evidence describing the benefits and positive health effects of moderate altitude. The limiting factor, however, is the fact that in very few studies
page 69 of 126 Healing Alps: Tourism based on natural health resources as strategic innovation for the development of Alpine regions ASP815 a mere stay at a moderate level represents the intervention. In most of the studies, the stay in moderate altitude is combined with an additional intervention, such as physical activity. Apart from that, involved participants of the studies are mostly not healthy, but subjects with a specific indication, which makes it difficult to draw gen- eral conclusions about a health benefit. Effects of altitude-training with the aim to improve maximum oxygen uptake and exercise performance due to hypoxic condi- tions and thus an increase of serum erythropoietin concentrations, is described in the section about high altitude.
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3.2.13 Apitherapy
Apitherapy is the medical use of honey products like honey, propolis, royal-jelly, bee- wax or bee venom to treat various diseases in complementary medicine. Since an- cient times, honey has been used for medical purpose for stimulating healing of wounds, tissue regeneration, and alleviating gastrointestinal disorders, gingivitis, and different other pathologies. The therapeutic effect of honey may result from the presence of various antioxidant molecules, including phenolic compounds, such as flavonoids and phenolic acids. Beekeeping and Apitherapy have a long tradition in European folk medicine (Al-Waili et al., 2014).
Figure: biological activities of honey and propolis (Pasupuleti, Sammugam, Ramesh, & Gan, 2017)
Medical Evidence Honey is the most ancient wound dressing biomaterial and the effectiveness of honey in the management of wounds has been confirmed by many studies. It is be- lieved that honey could be used as a suitable alternative option in most of the in- fected wounds due to its anti-bacterial and wound healing activity (Oryan, Alemza- deh, & Moshiri, 2018). Another, application is the inhalation of aerosolised honey to treat and man-age asthma. This treatment is only explored in rabbits and larger stud- ies in humans are needed to better understand the mechanisms by which aerosolised honey reduces asthma symptoms (Kamaruzaman, Sulaiman, Kaur, & Yahaya, 2014).
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(Oryan, Alemzadeh, & Moshiri, 2018) Bee Venom Therapy Bee venom therapy (BVT) uses bee venom for medical purpose. The diverse thera- peutic applications of BVT include various musculoskeletal conditions (e.g. arthritis, rheumatism) and immune-related diseases.
(Park, Yim, Lee, Lee, & Kim, 2015)
(J. A. Lee et al., 2014)
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(Seo, Han, Kwon, Jo, & Lee, 2017)
Psoriasis
(El-Gammal et al., 2018)
(Eltaher, Mohammed, Younes, & Elakhras, 2015)
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Tourism/regional prerequisites
• Beekeepers • Highly trained medical staff in case of bee venom therapy or wound car
Measurement
• HRQOL (specific Questionnaires e.g. PASI for psoriasis) • VAS for pain
Conclusion
The highest evidence for Apitherapy is centred on wound management. Wound management is not easy to implement in health tourism, as it requires highly trained medical personal and appropriate facilities. Cross sectoral innovations with local bee- keepers could be made. Workshops with local beekeepers in which participants can learn how to make simple wound dressings could be an easy to implement action.
3.2.14 Honey
Background
Honey is the natural sweet substance produced by Apis mellifera bees. The compo- sition, flavor and aroma of the honey depend on the plant sources, climate and envi- ronmental conditions. Honey is a nutritional food low in glycemic index. Honey intake reduces blood sugar levels and prevents excessive weight gain. It also improves lipid metabolism by reducing total cholesterol (TC), triglyceride (TG), low-density lipopro- tein (LDL) and increasing high-density lipoprotein (HDL), which leads to decreased risk of atherogenesis. In addition, honey enhances insulin sensitivity that further sta- bilizes blood glucose levels and protects the pancreas from overstimulation brought on by insulin resistance. Therefore, there is a strong potential for honey supplemen- tation to be integrated into the management of Metabolic Syndrome, both as pre- ventive as well as adjunct therapeutic agents (Ramli, Chin, Zarkasi, & Ahmad, 2018).
Medical Evidence
Metabolic Syndrome
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Metabolic syndrome (MetS) is a cluster of diseases comprising of obesity, diabetes mellitus, dyslipidemia, and hypertension. There are numerous pre-clinical as well as human studies reporting the protective effects of honey against MetS.
(Ramli et al., 2018)
(Meo et al., 2017)
Acute cough in children
(Oduwole, Udoh, Oyo-Ita, & Meremikwu, 2018)
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3.2.15 Alpine milk and dairy products
Background
An old farmersʼ proverb says that the grass is always better the higher one goes, and at the top it is so good that even farmers might like to eat it. In fact, with increasing elevation plant growth diminishes and with it the yields, but since the intensity of sunshine increases, Alpine plants process greater amounts of energy that leads to a higher protein and fat content. Animals react in a similar manner. Because of the de- mands of Alpine living on their bodies, animals are slower to fatten than during the same length of time in the valley, and milk output at higher altitudes is much lower than in the valleys. Although, it is also creamier when manufactured at higher eleva- tions: Still today, it contains between 15 and 30 percent more fat than in the valley. What is more, Alpine products were considered to be tastier and healthier because of herbs found only there, containing high percentages of ethereal oils (Orland, 2004).
The local flavour of the high mountainous meadows showed up again in their prod- ucts, which is why the cheeses were named after the Alpine pastures where they were produced. Urnerbödeler, Saanen or Emmentaler cheese: whole regions were identified with certain types of cheese. The links between landscape, animal and product represented a strain of thought with several components. The notion of dairy practices encompassed perceptions about the influence of the terrain on plants, an- imals and their products. When the first naturalists and doctors directed their atten- tion to the Alps, they soon discovered these links. Hippolyt Guarinonius, a doctor and humanist in the sixteenth century stated e.g. that the products of the lowlands could not match the quality of Alpine products (Orland, 2004).
Dairy production therefore has a long tradition in the Alpine region and has soon been associated with beneficial health outcomes. It plays a key role in the protection of the Alpine flora and fauna as well as in the preservation of regionally typical land- scapes. It is also integral to the ecological structure and cultural identity of the Alpine region and can therefore be a valuable product component in Alpine health tourism.
Medical Evidence
Milk and its derivates are useful foods throughout all life periods, in particular during childhood and adolescence, as their contents of calcium, protein, phosphorus, and other micronutrients can promote skeletal, muscular, and neurologic development. Especially Alpine milk and Alpine dairy products seem to have a health promoting nutritional value due to their composition (see card below). Generally, milk from grass-fed livestock is more beneficial than that of corn-fed animals (Visioli & Strata, 2014)
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(Hauswirth, Scheeder, & Beer, 2004)
Some studies also show, that milk consumption might have a protective effect on the development of allergies and asthma:
(Riedler et al., 2001)
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(Perkin & Strachan, 2006)
(Lluis et al., 2014)
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(Waser et al., 2007)
(Brick et al., 2016)
Conclusion
Studies indicate that milk consumption including unpasteurized milk consumption might explain the protective effect of farming on atopy seen in a wide range of stud- ies. However, it has to be mentioned, that most studies are cross-sectional studies. These associations to not confirm a causal relationship, and further investigation to identify specific protective agents or mechanisms is required. Some cohort studies have already been undertaken that support the protective effect of milk consump- tion. Although, more cohort studies are necessary to clarify the temporal sequence of exposure and outcome to identify critical periods of childhood when exposure to these putative protective agents or mechanisms might operate. It is also important
page 79 of 126 Healing Alps: Tourism based on natural health resources as strategic innovation for the development of Alpine regions ASP815 to mention that unpasteurized milk consumption is not hazard free, as milk-related outbreaks of Cryptosporidium species, Campylobacter species, and Escherichia coli O157 have been described (Perkin & Strachan, 2006). Therefore, it is important to un- derstand which components and mechanisms are underlying the observed protec- tive effect and risks to ultimately be able to utilize milk as a means of primary pre- vention. Until then, the consumption of raw milk cannot be safely recommended (Braun-Fahrländer & von Mutius, 2011).
Health tourism potential of Alpine milk and dairy products:
• Integration of alpine dairy products as product components in health tour- ism value chains
o Possible indications: Prevention of cardiovascular diseases, osteopo- rosis prevention, microbiome (further research needed)
• Farm holidays for families with kids in the first year of life for the prevention of allergies and asthma (needs further investigation, as most studies are cross-sectional, see also Chapter 3.2.10)
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3.2.16 Plants / Phytotherapy
Background
Alpine herbs and plants are an essential part of traditional European folk medicine. The knowledge of herbs was deeply rooted in the rural population, as it was difficult to get medical care. Therefore, indigenous plants and herbs were used for medical purposes. Today, Alpine herbs are witnessing a revival, as public interest in regional natural treasures grows.
Medical Evidence
Euphrasia officinalis (Eyebright)
Euphrasia officinalis, commonly known as eyebright, is an an- nual, herbaceous, semi-parasitic plant. The plant is found throughout Europe, Asia, and North America. It has traditionally been used as an eye lotion in the treatment and prevention of eye disorders such as conjunctivitis, ophthalmia, styes, and oc- ular allergies. In vitro studies revealed an immunomodulatory effect of Euphrasia officinalis (Paduch, Woźniak, Niedziela, & Rejdak, 2014) and a protective effect against UVB-induced photo aging of the skin (Liu et al., 2018). Studies regarding the effects of Euphrasia officinalis in humans are missing.
Alchemilla Vulgaris (Lady’s Mantle)
Alchemilla vulgaris (A. vulgaris; lady's mantle), a member of the Rosaceaea family, has traditionally been used to treat bleeding, eczema, inflammation, diarrhea, ulcers, skin rashes, menstrua- tion disorders and edema in Europe. It is also used as herbal tea for hypertension and as infusion for diabetes. Animal models provide evidence for blood pressure lowering effects. In com- parison to aqueous extract, the methanol extract of Alchemilla vulgaris has more prominent and favorable vascular effects (Takır et al., 2015).
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Achillea millefolium (Yarrow)
Yarrow is a flowering plant, native to the Northern Hemisphere. The herb has been used in traditional medicine as astringent, antiseptic and anti-inflammatory agent, to treat digestive dis- orders, menstrual irregularity, relieve menstrual cramps and pain, as antispasmodic agent to promote healing of cuts and wounds, burns and ulcers. However, further studies are re- quired to find the exact mechanism lying behind some of their pharmacological properties(Ali, Gopalakrishnan, & Venkatesalu, 2017).
Arnica montana
Arnica montana is widely used in the traditional European folk medicine to treat various ailments. Arnica extract is recognized for its antibacterial, antitumor, antioxidant, anti‐inflammatory, antifungal and immunomodulatory activity. The plant grows best in alpine regions at an altitude of 500 – 2500 m in less fertile meadows and on acidic soils in alpine meadows and peat bogs health- lands.
In homeopathic doses, oral arnica has been used for the treatment of swelling, the relief of mouth and throat inflammation, pain management and postoperative set- tings. Topically, arnica has been used for the treatment of bruises, aches, sprains, in- sect bites, trauma, arthritis, muscle and/or cartilage pain, chapped lips, irritated nos- trils, and acne.
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The beneficial effects of topical arnica are a controversial issue, as clinical studies are providing both, positive and negative results (Adkison, Bauer, & Chang, 2010); (Pumpa, Fallon, Bensoussan, & Papalia, 2014).
(Adkison et al., 2010); Pumpa et al., 2014; (Iannitti, Morales-Medina, Bellavite, Rot- tigni, & Palmieri, 2016; Pumpa et al., 2014)
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St. John’s Wort
Hypericum perforatum (more commonly known as St John's wort) is an herbaceous perennial plant com- monly found in Asia and Europe. St John’s wort grows on rocky hills along warm embankments of paths and wastelands. In traditional European folk medicine, topi- cal St. John’s wort preparations such as oils or tinctures are used for the treatment of minor wounds and burns, sunburns, abrasions, bruises, contusions, ulcers etc.
Beside such topical treatments, St. John’s wort is well established in the treatment of mild to moderate depressions (Ng, Venkata- narayanan, & Ho, 2017). Furthermore, animal models revealed beneficial effects of St. John’s wort, on stress induced impaired cognitive function(Trofimiuk, Holownia, & Braszko, 2011).
Although, St. John’s wort is associated with many positive health effects, clinical sig- nificant drug interactions are well known. Hyperforin, one of the main components of St. John’s wort affects the pharmacokinetics of various drugs. There are several clinical studies demonstrating the interaction of St. John’s wort with the metabolism of conventional drugs which may cause life-threatening events (Soleymani, Bahram- soltani, Rahimi, & Abdollahi, 2017). To ensure the safety of St. John’s wort conven- tional drugs should be studied systematically for interactions with St John's wort ex- tracts (Chrubasik-Hausmann, Vlachojannis, & McLachlan, 2019).
(Ng et al., 2017; Mansouri et al., 2017)
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3.2.17 Winter - snow-based activities
White Exercise
Especially in times of growing urbanization, the health-promoting effects of physical activity are more important than ever: “Lifestyle diseases” such as cardiovascular dis- eases, diabetes type II, obesity, high blood pressure, allergies or even psychological diseases such as depression or anxiety disorders are on the rise. On the one hand, this is due to a sedentary lifestyle (in the average we generally move too less) com- bined with an unbalanced diet and high stress potential due to urban crowding ef- fects, such as stimulus flooding, noise, competitive pressure, etc. (Cadilhac et al., 2011). On the other hand, we spend too much time in closed rooms (>90 %!) and when we go outside, the environment and air quality play an important role. Besides a proven positive psychological effect of unspoilt nature on humans, nature can also score with a higher concentration of negative air ions and a reduced fine dust pollu- tion. Particularly in winter, when the air is even more polluted by rolling chippings, heating, etc., physical exercise ouside in the fresh air is recommended: "White Exer- cise" (winter sports).
Physical activity significantly improves cardiorespiratory fitness and increases our ca- pacity to absorb oxygen. This improves our performance and blood circulation, so that every cell in our body is optimally supplied with oxygen. Movement also releases more endorphins in the brain, which has a mood-enhancing and activating effect on us.
Regular exercise also has an influence on our immune system and has an anti-inflam- matory effect: People with a sedentary lifestyle and overweight usually have a mild, chronic inflammation (Gleeson et al., 2011). Immune cells such as monocytes (M1) in- filtrate visceral fat and produce pro-inflammatory messengers (cytokines). Muscle activity leads to the formation of anti-inflammatory cytokines (e.g. IL-10) and the re- duction of pro-inflammatory cytokines (e.g. TNF α). Physical activity and exercise re- duce excess fat tissue and simultaneously stimulates the HPA axis (brain-activated hormone production in the adrenal glands), turning a pro-inflammatory M1 pheno- type as present due to lack of exercise, into an anti-inflammatory M2 phenotype. The release of immunoinhibitory glucocorticoids and catecholamines such as cortisol and adrenalin/noradrenalin by activation of the HPA axis leads to reduced secretion of pro-inflammatory cytokines such as TNFα from immune cells (e.g. monocytes). In ad- dition, more interleukin 6 is produced by the working skeletal muscles, which also inhibits the secretion of TNFα and initiates further anti-inflammatory processes.
A regular moderate physical activity supports our immune system in many ways and counteracts numerous diseases. Physical exercise has been shown to reduce the in- flammatory capacity of leukocytes (less TLR expression (Gleeson, McFarlin, & Flynn, 2006)), increases the number of neutrophils in the blood and promotes phagocytosis activity (Sasaki et al., 2013).
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Regular physical exercise reduces the resting pulse and sympathicotonus, strength- ens our muscles, including the heart muscle, and increases the heart rate variability. Exercise reduces both cholesterol and blood sugar levels, thus significantly reducing the risk of cardiovascular disease or type 2 diabetes. Even age-related hypertension can be counteracted by physical activity by prolonging the endothelial function. If we regularly cover a distance of 50 km/week, our mortality is even halved (Paffenbarger, Hyde, Wing, & Hsieh, 1986). Regular physical activity strengthens our immune system, reduces susceptibility to infections and has a protective effect against the most com- mon civilization diseases. Outdoor exercise and contact with nature provides an ad- ditional cognitive and health-promoting effect (T. Hartig, Mitchell, de Vries, & Frum- kin, 2014).
Sledging
Sledging/tobogganing is a winter sport for everyone and a great opportunity to o expand the range of leisure activities available to tourists: a sledge, a little body ten- sion and some driving feeling - more is not necessary for this sport, as long as a well prepared and safe toboggan run is available. The cardiorespiratory health success of sledging is limited, but neither an extraordinarily good state of fitness nor special technical skills are required. Tobogganing is nevertheless healthy, as it benefits from the mountain air, which is low in fine dust and allergens, as well as from the increased ion concentration and UV radiation. Braking manoeuvres challenge the leg muscles and the ability to react is also trained. Apart from that, tobogganing on a good track and equipped with the right clothes (warm, waterproof, sturdy shoes, gloves) is a lot of fun and brings a lot of smiles, which is proven to be very healthy in multiple ways (Berk, Felten, Tan, Bittman, & Westengard, 2001; Berk et al., 1989; Hayashi et al., 2016; Titze, Finnegan, Laukkanen, Fuja, & Hoffman, 2008). The most import thing to men- tion in connection with this sport is the relatively high risk of injury. Besides wearing safety clothing (helmet and ski goggles), there are some necessary protective measures which absolutely must be considered:
• Safe steering and braking of the toboggan
• Adapting speed to the conditions, anticipating driving
• Use sledges with the TÜV seal or GS mark for tested safety
• Only sledge on designated, safe runs, the snow cover should not be frozen.
• Small children should not sledge alone
• Upright sitting position with upper body slightly inclined backwards
Alpine Ski
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Skiing is the main reason for a winter holiday in the Alps. It also has a positive effect on our health and well-being. Regarding the main parameter of cardio-respiratory fitness, the maximum oxygen capacity (VO2max), Alpine skiing is an efficient way to increase performance in winter (T. L. Stoggl et al., 2017). Skiing primarily trains the leg muscles, but arms and upper body are also required. Considering the breaks during lift rides, alpine skiing converts about 400 kilocalories per hour. Since skiing promotes leg strength and balance, it can be an effective preventive measure for the growing target group of best agers (60 years and older) to maintain physical fitness and pre- vent falls (Muller et al., 2011). Skiing also reduces some cardiovascular risk factors and prevents atherosclerosis and type 2 diabetes (Dela et al., 2011; Niederseer et al., 2011, 2016). A reduced sympathetic activity, which can also be induced by skiing, also has a cardioprotective effect (Kanh, Jouanin, Bruckert, Guezennec, & Monod, 1996).
Medical Evidence
(Muller et al., 2011)
(Dela et al., 2011)
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(Niederseer et al., 2011)
(Niederseer et al., 2016)
(T. L. Stoggl et al., 2017)
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(Kanh et al., 1996)
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Cross-Country Skiing
Cross-country skiing trains the whole body, especially the back muscles. It is one of the sports with the highest oxygen metabolism (VO2max), trains endurance and has a very large cardiorespiratory health effect (T. Stoggl et al., 2016). Within one hour, about 800 to 1000 kilocalories are burned during cross-country skiing. In cross-coun- try skiing, numerous different techniques are used, whereby two basic styles are dis- tinguished: classic and free cross-country skiing, the latter also known as “skating”. The classical style is the older one and until the 1980s it was the only existing tech- nique in cross-country skiing. The skis are guided parallel and pushed straight back- wards, not sideways. For classic cross-country skiing you need a groomed cross- country ski slope. In contrast to the classic style, skating also requires a prepared track, but no grooming is necessary. When skating, you use the ski similar to the movement when skating or inline skating and push off to the side (skate step). Skat- ing skis have no grip zone in the middle of the ski, which is necessary for the classic style, but are developed for optimal gliding; the average speed is also significantly faster than with the classic technique. Due to the different use of poles and a lower lateral stability of the ski due to the missing track, the free cross-country style is more difficult to learn and more strenuous than the classic style.
Cross-country skiing has a very low risk of injury and long-term damage to health but offers a lot of health benefits. It strengthens the upper and lower body and promotes cardiovascular health. Cross-country skiers suffer less frequently from overweight, have better health behaviour and less risk of developing cardiovascular disease (An- derson, Bovard, Murad, Beebe, & Wang, 2017). The cancer associated, cardiovascular and even the general mortality rate of Swedish cross-country skiers is significantly reduced compared to the total population (Nagle, 2015). A follow-up population study published in 2017 in Finland with over 2000 participants found that general mortality is inversely and independently associated with frequency and duration of recreational cross-country skiing (Laukkanen, Laukkanen, & Kunutsor, 2017).
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Medical Evidence
(T. Stoggl et al., 2016)
(Anderson et al., 2017)
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(Laukkanen et al., 2017)
Ski Mountaineering
Ski mountaineering has become the winter sports trend number one: The reward ef- fect of an adventurous descent on unprepared slopes after a strenuous ascent through unspoilt, quiet winter landscapes clearly has an addictive potential. In order to prevent injuries, however, one should have a good level of fitness in order to have sufficient reserves of strength for a safe descent. One should also be well prepared in terms of driving technique, as in open terrain, besides the hotly sought-after downhill runs on powder snow, unfavourable snow conditions can also prevail. Good equipment (including avalanche beeper, probe and shovel) as well as knowledge of the terrain, the weather and the avalanche risk are also indispensable for ski moun- taineering.
Ski mountaineering has the highest MET factor of all the common winter sports, burns a lot of energy and kilocalories and is therefore a highly effective sport to im- prove cardio-respiratory fitness (Tosi, Leonardi, & Schena, 2009). The prevalence of cardiovascular disease in ski mountaineers is greatly reduced (M. Faulhaber, Flatz, Gatterer, Schobersberger, & Burtscher, 2007). Ski mountaineering not only trains en- durance and strength, it is also used as a recovery and regeneration measure (Hjuler & Bay, 2016).
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Medical Evidence
(M. Faulhaber et al., 2007)
(Tosi et al., 2009)
Snowshoeing
Snowshoeing can be compared to Nordic Walking. It is gentle on the whole body and suitable for all ages. The calorie consumption of hiking in deeper snow with snow shoes is with about 500 kilocalories within one hour higher than the metabolic costs of normal walking (Browning, Modica, Kram, & Goswami, 2007). Due to a greater hip and knee flexion during stance and a greater hip flexion during swing while snow- shoeing, muscle parts different to walking without snowshoes are trained. Especially for women often wearing high-heels snowshoeing can be advantageous, as negative effects like a tightening of the hamstring can be counteracted (Browning, Kurtz, & Kerherve, 2012).
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3.2.18 Winter - Not snow-based activities
Winter Hiking
Winter hiking is possible on all hiking trails that are approved and mapped as such in terms of avalanche danger and walkability in winter. The calorie consumption for one hour of winter hiking is around 250 kilocalories. The movement in the sun in the fresh air releases the “happiness hormone serotonin”, which counteracts both physical stress reactions and the "winter blues" thus lifting the mood (Gupta, Sharma, Garg, Singh, & Mondal, 2013; Morris & Hardman, 1997). Winter hiking is particularly suitable for overweight people and those affected by the metabolic syndrome (high blood pressure, abdominal obesity, fat metabolism disorders and increased blood sugar). Winter hiking reduces physiological parameters such as blood pressure and heart rate, supports the weight loss and improves cholesterol and sugar metabolism (Greie et al., 2006; Mair et al., 2008; Neumayr et al., 2014; Wolfgang Schobersberger et al., 2005).
Medical Evidence
(Prossegger, Huber, Grafetstätter, Pichler, Braunschmid, et al., 2019)
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(Morris & Hardman, 1997)
(Neumayr et al., 2014)
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Ice Skating
Whether on a lake or prepared ice surfaces in the city, ice skating is a popular winter sport. It is not only fun and easy to learn, but also very healthy. Ice skating is a mod- erate endurance training and an ideal support when losing weight. Gliding over the ice therefore does a lot for your cardiovascular system. You also train coordination, balance and body control when skating. It trains many muscle groups, especially thighs, back, but also buttocks and arms, if you let them swing. Like running out- doors, ice skating stimulates the blood circulation and helps the body to cope better with temperature fluctuations. Additionally, the fresh air strengthens the immune system.
When skating on frozen natural water instead of in the hall, only enter ice surfaces if they have been officially cleared. Knee, elbow protectors and a helmet are recom- mended to prevent injury in falls.
Medical Evidence
There is a lot of medical evidence concerning ice skating and its effects on the human body, but only in turns of elite athletes and professional ice skating or ice hockey. Evidence of the medical impact of ice skating in the amateur sector is missing.
Conclusion
In summary, the Alpine region offers a wide range of physical activities, from which numerous tourist leisure activities can be derived.
In times of growing urbanization, the health-promoting effects of physical activity especially in winter are more important than ever: "Lifestyle diseases" such as cardi- ovascular diseases, diabetes type II, obesity, high blood pressure, allergies or psycho- logical diseases such as depression or anxiety disorders are on the rise. On the one hand, this is due to a sedentary lifestyle (the average citizen generally moves too lit- tle) combined with an unbalanced diet and high stress potential due to urban crowd- ing effects, such as stimulus flooding, noise, competitive pressure, etc. On the other hand, the effects of the sedentary lifestyle are also increasing. (Cadilhac et al., 2011). On the other hand, we spend too much time in closed rooms (>90 %!). When we then go out, the environment and air quality play a major role. In addition to a proven positive psychological effect of unspoilt nature on humans, nature can also score points with a higher concentration of negative air ions and reduced fine dust pollu- tion. Particularly in winter, when the air is even more polluted by rolling chippings, heating, etc., physical exercise in the fresh air in the great outdoors is recommended.
Physical activity significantly improves cardiorespiratory fitness and thus massively increases our capacity to absorb oxygen. This improves our performance and blood
page 96 of 126 Healing Alps: Tourism based on natural health resources as strategic innovation for the development of Alpine regions ASP815 circulation, so that every cell in our body is optimally supplied with oxygen. Move- ment also releases more endorphins into the brain. This has a mood-enhancing and activating effect on us. Regular exercise strengthens our immune system, reduces susceptibility to infections and has a protective effect against the most common dis- eases of civilization. Contact with nature provides additional cognitive and health- promoting factors.
Provided that safety precautions are observed, these activities are generally healthy and ben-eficial to the body, even if medical evidence is lacking for some of the men- tioned activities in the in the amateur field or leisure sector. A possible variation of not snow-based activities are theme-walks. In the health tourism sector, there is still a need for research in this area in order to determine the concrete health effects.
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3.2.19 Radon
Background
Since the beginning of the twentieth century, radon therapy has been applied in mid- dle Europe. Radon therapy uses the chemically inert naturally radioactive gas radon, to treat various diseases. Its main application is found as a non-pharmacological treatment option for various inflammatory rheumatic diseases. For treatment pur- poses, radon is commonly applied by bathing for about 20 min in water with a radon concentration of 0.3–3 kBq/L or staying for about 1 h in caves or galleries with natural radon concentrations of about 30–160 kBq/m3.
Medical Evidence
Rheumatic Diseases
Recent treatment regimens of rheumatoid arthritis (RA) include disease-modulating and symptomatic drug therapy as well as multimodal rehabilitative programmes aiming at long-term disease management with pain relief, preservation of remaining functions and development of compensatory functions.
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(Falkenbach, Kovacs, Franke, Jörgens, & Ammer, 2005); (Franke, Reiner, & Resch, 2007); (Franke & Franke, 2013)
Osteoporosis
Osteoporosis is a widespread systemic skeletal disease characterized by decreased bone mass. Secondary osteoporosis is a frequent complication of rheumatoid arthri- tis.
(Lange et al., 2016; Winklmayr et al., 2015)
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Chronic airway disease, pain, hypertension and antioxidant effects
In a recent pilot study, beneficial effects of radon spa therapy on the total antioxidant status were observed (Kuciel-Lewandowska, Pawlik-Sobecka, Płaczkowska, Kokot, & Paprocka-Borowicz, 2018).
(Passali, Gabelli, Passali, Mösges, & Bellussi, 2017)
(Rühle et al., 2019)
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3.2.20 Speleotherapy
Description
Speleotherapy is a special kind of climate therapy, which uses the specific microcli- mate of mines and caves to treat especially respiratory and skin related diseases. Speleotherapy is relatively widespread in Europe. Speleotherapy facilities vary in their environmental conditions, including radiation level, temperature, humidity. In most caves, patients are advised to rest during this period. In some caves physical exercises or breathing exercises, including salt aerosols, are recommended.
Medical Evidence
(Beamon, Falkenbach, Fainburg, & Linde, 2001) (Gaus & Weber, 2010)
Conclusion
Little scientific evidence is available for Speleotherapy. Caves and mines vary in their specific conditions. Therefore, further research is needed to evaluate the specific ef- fects of Speleotherapy.
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5 Figures
Figure 1: HEALPS work packages...... 4
Figure 2: Identified Alpine natural health resources ...... 6
Figure 3: Extract from the HEALPS database ...... 7
Figure 4: Indication-based approach to the medical-scientific characterization of Alpine resources ...... 8
Figure 5: Protected Areas in the Alps; Source: (ALPARC, 2018) ...... 53
6 Tables
Table 1: AHCPR Evidence levels ...... 8
Table 2: Content of checklist for the identification of health-related p/s/a ...... 9
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