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The Role of Exercise in Medicine
Exercise Is a Relatively New Scientific Discipline:
It Has Important Foundations in Scandaniva
Beginnings of Exercise Science Exercise scientists have won the
Nobel Prize• August Krogh—1920
Capillary regulation
• A. V. Hill and Otto Meyerhof—1922 Muscle metabolism
Early leaders in exercise science in Scandinavia• Erik Christensen • P.O. Astrand• Erik Assmussen • Marti Karvonnen
Articles/Period—Web of SciencePhysical Activity or Physical Fitness and
Cardiovascular Disease# of Articles
Years
Ranking of selected risk factors: 6 leading causes of death by income group, estimates for 2004
Percentage of total (total: 1.53 billion)
World Health Organization. http://www.who.int/healthinfo/global_burden_disease/global_health_risks/en/index.htm
Risk Factors for Stroke in 22 Countries: INTERSTROKE Study
O’Donnell MJ et al. Lancet 2010; 376(9735):112-123
Adjusted for age, sex, and region
Self-reported Physical Activity Underestimates the True Effect
• 31,818 men and 10,555 women
• 1492 deaths in men during average follow-up of 14.6 years, and 230 deaths in women during average follow-up of 12.8 years
• PA mortality trends not significant after adj for CRF
• CRF trends significant after adj for PA
Phys Act CRFLee DC, et al. BJSM; pub online April 23, 2010
Aerobics Center Longitudinal Study
Design of the ACLS
1970 More than 80,000 patients 2005
Mortality surveillance to 2003More than 4000 deaths
Cooper Clinic examinations--includinghistory and physical exam, clinical tests,body composition, EBT, and CRF
1982 ‘86 ‘90 ‘95 ’99 ‘04Mail-back surveys for case finding and monitoring habits and other characteristics
All-Cause Death Rates by CRF Categories—3120 Women and
10 224 Men—ACLS
0
10
20
30
40
50
60
70
Ag
e ad
j dea
th r
ate/
10,0
00 P
Y
Low Moderate High
Women
Men
Blair SN. JAMA 1989
Does Changing Cardiorespiratory Fitness
Reduce Mortality Risk?
Fitness Change Categories Unfit was defined as the least fit 20% of men
in each age group Men were classified as fit or unfit at both
examinations Change categories
• unfit at both examinations = never fit• unfit at first, fit at second = improvers• fit at both examinations = always fit
Blair SN et al. JAMA 1995; 273:1093-8
Age-Adjusted Death Rates by Fitness Change Groups, Men, ACLS
Age-adjusted Death Rates/10,000 Man-years
Fitness Groups
CVD All-cause
Never fit 65 122
Improvers 31 68
Always fit 14 40
Blair SN et al. JAMA 1995; 273:1093-8
CRF and Risk of Incident Hypertension, ACLS Women
4,884 healthy women examined at the Cooper Clinic, 1970-1998
157 women developed hypertension during average follow-up of 5 years
Risk adjusted for age, exam year, alcohol intake, smoking, BP, family history of hypertension, waist girth, glucose, & triglycerides
FitnessGroups
Risk of Developing Hypertension
Barlow CE et al. Am J Epidemiol 2006; 163:142-50
P for trend <0.01
CRF and Digestive System Cancer Mortality
•38,801 men, ages 20-88 years•283 digestive system cancer deaths in 17 years of follow-up
CRF was inversely associated with death after adjustment for age, examination year, body mass index, smoking, drinking, family history of cancer, personal history of diabetes•Fit men had lower risk of colon, colorectal, and liver cancer deaths
High Fit
Moderately Fit
Low Fit
Peel JB et al. Cancer Epidemiol Biomarkers Prev 2009; 18:1111
CRF and Breast Cancer Mortality
•14,551 women, ages 20-83 years•Completed exam 1970-2001•Followed for breast cancer mortality to 12/31/2003•68 breast cancer deaths in average follow-up of 16 years•Odds ration adjusted for age, BMI, smoking, alcohol intake, abnormal ECT, health status, family history, & hormone use
Odds Ratio
p for trend=0.04
Sui X et al. MSSE 2009; 41:742
Activity, Fitness, and Mortality in Older Adults
Cardiorespiratory Fitness and All-Cause Mortality, Women and Men ≥60 Years of Age
4060 women and men ≤60 years
989 died during ~14 years of follow-up
~25% were women Death rates adjusted
for age, sex, and exam year
0
5
10
15
20
25
30
35
40
45
60-69 70-79 80+
Low
Moderate
High
All-Cause death rates/1,000 PY
Age Groups
Sui M et al. JAGS 2007.
Physical Activity as Treatment for Chronic Disease
Exercise Is Medicine!
Cardiorespiratory Fitness and Health Outcomes in Various
Population SubgroupsSuch as People Who Are Overweight or Obese or
Those with Chronic Disease
Cardiorespiratory Fitness, Risk Factors and All-Cause Mortality, Men,
ACLS
0
10
20
30
40
50
60
De
ath
s/1
0,0
00
MY
*
Low Mod High
01
2 or 3
# of risk factors
Risk Factorscurrent smokingSBP >140 mmHgChol >240 mg/dl
Cardiorespiratory Fitness Groups*Adjusted for age, exam year, and other risk factors
Blair SN et al. JAMA 1996; 276:205-10
CVD Mortality Risk* by Fitness and BMI Categories, 2316 Men with Diabetes,
179 CVD Deaths
0
1
2
3
4
5
6
7
8
9
10
Ris
k o
f C
VD
Mo
rta
lity
18.5 < BMI <25.0 25.0 ≤ BMI <30.0 30.0 ≤ BMI < 35.0
Re
fere
nc
e
Church TS et al. Arch Int Med 2005; 165:2114*Adj for age and examination year
p for trend <0.0001p for trend <0.0001 p for trend <0.002
0
2
4
6
8
10
12
14
16
18
LowModerateHigh
Controlled HTN Stage 1 HTN Stage 2 HTN
Severity of HTN
P <.001 P <.001 P =.048
CRF:
Age and exam year adjusted rates of total CVD events by levels of CRF and severity of HTN in
8147 hypertensive men
Sui X et al. Am J Hyptertension. 2007
CVD incidence/1000 man-years
Multivariate + % Body Fat adjusted HR of All-Cause Mortality by Fitness Groups,
ACLS, 2603 Adults 60+
0
0.2
0.4
0.6
0.8
1
1.2
Q1 Q2 Q3 Q4 Q5
Adjusted HR
p for trend <0.001
Cardiorespiratory Fitness
106 deaths
98 deaths95 deaths
90 deaths61 deaths
*Adjusted for age, exam year, smoking, abnormal exercise ECG, baseline health conditions, and percent body fat Sui M et al. JAMA 2007; 298:2507-16
Joint Associations of CRF and % Body Fat with All-cause Mortality, ACLS Adults 60+
0
10
20
30
40
Fit Unfit
Normal
Obese
Death rate/1,000 person-years
Rates adjusted for age, sex and exam year
Deaths 151 190 29 72
Sui M et al. JAMA 2007; 298:2507-16
Muscular Strength and Mortality
Thirds of Muscle Strength and Thirds of Muscle Strength and Mortality, 8762 Men--ACLSMortality, 8762 Men--ACLS
0
5
10
15
20
25
30
35
40
Age adj death rate/10,000
MY
All-Cause CVD
Low
Middle
High
503 deaths (145 CVD) during average follow-up of 18.9 years
Ruiz J et al. BMJ 2008
Strength, Adiposity, and Cancer Mortality•8,677 men, 20-82 years•18.8 years of follow-up, 211 cancer deaths•Muscular strength assessed by 1-RM bench press and leg press •Significant trend across strength categories remained after further adjustment for BMI, % body fat, waist circumference, and cardiorespiratory fitness Thirds of Strength
Odds of Cancer Death*
*Adj for age, exam yr, smokingalcohol intake, and health status
P for trend=0.003
Ruiz J et al. Cancer Epidemiol Biomarkers Prev 2009; 18:1468
Attributable Fractions (%) forAll-Cause Deaths
40,842 Men & 12,943 Women, ACLS40,842 Men & 12,943 Women, ACLS
02468
1012141618
Low CRF
Obese
Smoker
Hypertension
High Chol
Diabetes
MenWomen
Blair SN. Br J Sports Med 2009; 43:1-2.
Yes, But Those Are Observational Studies, and
We Require Randomized Clinical Trial Evidence
Reduction in Risk of Developing Diabetes in Comparison with Controls,
DPP
58%
31%
0
20
40
60
80
100
Ris
k re
du
ctio
n (
%)
*Moderate intensity exercise of 150 min/week; low calorie, low fat diet
Lifestyle Intervention* Metformin
DPP Research Group. NEJM 2002; 346:393-403
Cost Effectiveness of Diabetes Prevention-DPP
The lifestyle and metformin groups cost $2,250 more/year than placebo
As implemented in the DPP and from a societal perspective, lifestyle was more cost effective than metformin
$0$10,000$20,000$30,000$40,000$50,000$60,000$70,000$80,000$90,000
$100,000
Per C
aseD
elayed/P
rev
Per Q
AL
YG
ained
Lifestyle
Metformin
DPP Res Group. Diab Care 2003; 26:2518
8.58.7
7.57.98.0
6
7
8
9
10
0 6 12
Sco
re
Physical activitySuccessful aging
P<0.001
mo mo
Means estimated from repeated measures ANCOVA adjusted for gender, field center and baseline values
LIFE-P SPPB Score
J Gerontol Biol Sci Med Sci 2006;61:1157
Physical activityN=213
Successful agingN=211
p
Death 0.9% 0.9% >0.99Life threatening event 1.4% 1.4% >0.99Hospitalization 20.7% 20.9% >0.99Significant lab exam 2.8% 3.8% 0.60Any SAE 22.5% 23.7% 0.82
LIFE-P Serious adverse events
J Gerontol Biol Sci Med Sci 2006;61:1157
Exercise Is Medicinewww.exerciseismedicine.org
Exercise Is Medicine World Congress
Denver, COMay 31-June 2, 2010
What should I do in my clinical practice to promote
physical activity?
Physician Competencies for Prescribing Lifestyle Medicine “The leading causes of death for
adults in the United States are related to lifestyle—tobacco use, poor diet, physical inactivity, and excessive alcohol consumption”
“The enormous potential effects of health behavior change on mortality, morbidity, and health care costs provide ample motivation for the concept of lifestyle medicine…”
Lianov & Johnson. JAMA 2010; 304:202-3.
Physician Competencies for Prescribing Lifestyle Medicine
Lifestyle change is recommended therapy, but often not done…• 36% of obese patients are advised to
lose weight during an examination• 28% of smokers report that clinicians
offered them assistance to quit smoking Physicians lack confidence of their
knowledge and skill for lifestyle counseling
Lianov & Johnson. JAMA 2010; 304:202-3.
Physician Competencies for Prescribing Lifestyle Medicine Lifestyle medicine competencies
for primary care physicians• Leadership• Knowledge• Assessment skills• Management skills• Use of office and community
support
Lianov & Johnson. JAMA 2010; 304:202-3.
Risk of all-cause mortality decreases with number of positive health factors
Prospective study of 38,110 men, age 20-84 yrs
Positive health factors• Moderate to high CRF (top two-thirds
CRF)• Physically active (moderate to high
LTPA)• BMI (18.5 – 25.0 kg/m2)• Smoking (not current smoker)• Alcohol consumption (1-14
drinks/week) Average follow-up of 16.1 yrs, and 2,642
deaths
Byun et al. MSSE 2010; 42(9):1632-1638
HR* According to the Number of Positive Health Factors for All-Cause Mortality
Byun et al. MSSE 2010; 42(9):1632-1638
P for trend <0.001
*Adjusted for age, examination year, hypertension, diabetes, and hypercholesterolemia
Physical Activity Interventions in Clinical
Practice
Karolinska Institute• 101 participants 68-years old
with low PA, overweight and abdominal obesity
• Randomized to physical activity on prescription (PAP) or a minimal intervention
• Physical activity, anthropometric parameters, body composition and cardiometabolic risk factors
Kallings L et al. Euro.J.Cardio.Preven.Rehab. 2009. 16:80-84.
Karolinska Institute• Favorable changes in
anthropometrics, body composition, S-glucose, glycosolated hemoglobin, blood lipids and apolipoproteins were seen in the PAP group
Kallings L et al. Euro.J.Cardio.Preven.Rehab. 2009. 16:80-84.
Where Do We Go from Here?
Behavioral Approaches to Physical Activity Interventions
Theoretical foundations• Social Learning Theory• Stages of Change Model• Environmental/Ecological Model
Methods• Problem solving• Self-monitoring• Goal setting• Social support• Cognitive restructuring• Incremental changes• Manipulating the environment
Track Record of Lifestyle PA Interventions
Successfully implemented in many different populations and settings• Men and women of all ages• African-American men and women,
Hispanic women• Prostate cancer survivors• Worksites, YMCA’s, public heath
departments, recreation facilities, senior centers, churches
Lessons Learned from Physical Activity Intervention Studies
Individuals who use cognitive and behavioral strategies are more likely to be active at 24 months than individuals who do not use these strategies
Approximately 25-30% of initially sedentary persons who participate in Active Living will be meeting consensus public health guidelines for physical activity at 24 months
Using Modern Technology to Promote Healthful
Lifestyles
How to Achieve Lifestyle Change
Counseling by a PhD level behavioral psychologist
Counseling by B.A. level health educators
Counseling by mail and telephone
Counseling by electronic communications
Telehealth and Weight Change•87 participants (73 women & 14 men)•Mean age 50 years•Treatment groups (Quasi-experimental design)
•Traditional class•Telehealth—interaction with RD via web and email•Control
•No difference in satisfaction between traditional and telehealth•Telehealth more convenient than traditional (p<0.0001)
Kg change at 6 mo
Traditional Telehealth Control
p <0.05
Haugen HA et al. Obes 2007; 15:3067-77
Promoting PA via PDA 37 healthy, inactive adults, ≥50 years of
age 8-week RCT PDA intervention (93% had not used
PDAs)• Questions about amount and type of PA • Alerted at 2 PM and 9 PM to complete PA
assessment• Gave motivational and behavioral tips
Controls—standard written materials
King AC et al. Am J Prev Med 2007; 34:138-42
Promoting PA via PDA Intervention participants completed 68%
of the 112 PDA entries available After adjusting for baseline differences
• PDA group reported 310.6 minutes of moderate to vigorous PA/week
• Control group reported 125.5 minutes/week• p=0.048 for group comparison
78.6% of PDA group reported enjoying using the device
King AC et al. Am J Prev Med 2007; 34:138-42
The SenseWear Armband (SWA)The SenseWearTM Armband
(BodyMedia, Pittsburgh, PA) Lightweight monitor worn on the
upper left arm Four sensors (skin temp,
galvanic skin response, heat flux, tri-axial accelerometer)
Estimates energy expenditure Physical activity – duration &
intensity
Effects across time for weight. Estimates adjust for age, gender, race, education, and wave.
Standard Care
GWL
GWL=Group Weight LossSWA=SenseWear Armband
Shuger S et al. In review
Summary Physical inactivity and low fitness
are highly prevalent in modern societies
Inactivity and low fitness are strong determinants of morbidity and mortality due to chronic disease
Comprehensive programs to increase activity are crucial to the public’s health
Physicians and other health care professionals can make a difference via Exercise Is Medicine
Acknowledgements Co-investigators
• Xuemei Sui• Tim Church• James Hebert• Greg Hand• Ian Janssen• Francisco Ortega• Jonatan Ruiz• Steve Hooker• Michael Beets• Sara Wilcox• Chris Riddoch• Andrew Jackson• Paul McAuley• Susumu Sawada• Andy Ness
Post-doctoral scholars• D.C. Lee• Meghan Baruth• Jongkyu Kim• Enrique Artero
PhD students• Amanda Paluch• John Sieverdes• Vaughn Barry• Jonathan Mitchell• Won Byun• Tatiana Warren• Andrea Maslow• Will Lyely
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