Exercise as Medicine Michael J. Falvo, PhD, RCEP

Exercise as Medicine Michael J. Falvo, PhD, RCEP

Exercise as Medicine Michael J. Falvo, PhD, RCEP Jacquelyn C. Klein, MS, RCEP Effects of Physical Inactivity Cardiorespiratory Fitness Effects of Chronic Exercise Training Components of an Exercise Prescription Individualizing Exercise Prescription Provider Resources Effects of Physical Inactivity

Cardiorespiratory Fitness Effects of Chronic Exercise Training Components of an Exercise Prescription Individualizing Exercise Prescription Provider Resources Physical inactivity accounts for 3.2 5 million deaths per year By reducing physical inactivity 10-25% 0.5 1.3 million

premature deaths could be averted Lim et al. Lancet 2012; 380: 222460 Lee et al. Lancet 2012; 380: 21929 Gains in Life Expectancy Lee et al. Lancet 2012; 380: 21929 Global Burden Smoking vs. Inactivity Wen and Wu. Lancet 2012; 380 (9838), pp. 192-193. S0140-6736(12)60954-4 Physical Inactivity in US Adults

http://www.cdc.gov/physicalactivity/data/facts.html Uniqueness of Veterans Compared to civilian patient population, the VA patient population 15-fold poorer health 14-fold more conditions 5-fold more admissions Physical Activity? Agha et al. Arch Intern Med 2000;

160(21):3252-3257. Veterans vs. Civilians Littman et al. Med Sci Sports Exerc 2009; 41 (5), pp.10061013 VA Users vs. Non-Users Littman et al. Med Sci Sports Exerc 2009; 41 (5), pp.1006-1013

The Active Couch Potato 30 minday of - moderate intensity physical activity 71% of waking hours being sedentary Owen et al. Exerc Sport Sci Rev 2010; 38:105-113

Designed to Sit? 55 - 70% of waking hours are spent sedentary TV viewing associated with obesity, diabetes, insulin resistance, impaired glucose uptake Medical Hazards of Prolonged Sitting Bassett et al. Exerc Sport Sci Rev 2010; 38 (3): 101-2 juststand.org Sedentary Time Independent Risk? Maher et al. PLoS ONE 2014; 9(1): e86403.

Non-Exercise Physical Activity Ekblom-Bak E, et al. Br J Sports Med 2013;48:233238 Physical Inactivity Risky Business 70% 60% 50% 40% 30% 20% 10%

0% Katzmarzyk & Janssen. Can J Appl Physiol 2004; 29, 90-115 Effects of Physical Inactivity Cardiorespiratory Fitness Effects of Chronic Exercise Training Components of an Exercise Prescription Individualizing Exercise Prescription Provider Resources Cardiorespiratory Fitness (CRF) CRF is a health-related component of physical

fitness defined as the ability of the circulatory, respiratory, and muscular systems to supply oxygen during sustained physical activity. METs VO max Aerobic capacity Lee et al. J Psychopharm 2010; 24:27-35 CRF and Mortality 5 Increasing METs Relative Risk of Death

4 3 Healthy CVD 2 1 0 1 2

3 4 Quintiles of Exercise Capacity Myers et al. NEJM 2002 ; 346(11):793-801 5 What about Risk Factors?

Myers et al. NEJM 2002 ; 346(11):793-801 CRF and Mortality (n = 15,660) 1.2 1 Relative Risk of Death 0.8 0.6 0.4 0.2 0

Kokkinos P, Myers J. Circulation 2010;122(16):1637-1648 What about Risk Factors? 1.6 1.4 Risk Factors No Risk Factors Relative Risk of Death

1.2 1 0.8 0.6 0.4 0.2 0 Kokkinos P, Myers J. Circulation 2010;122(16):1637-1648 < 5 METs

5.1-7 METs 7.1-10 METs > 10 METs Survival Benefit per MET Goraya et al. 2000 (n = 514) Goraya et al. 2000 (n = 2593) Dorn et al. 1999 (n = 315) Baladay et al. 2004 (n = 3043) Gulati et al. 2003 (n = 5271) Mora et al. 2003 (n = 2994)

Myers et al. 2004 (n = 6213) Myers et al. 2002 (n=6213) Blair et al. 1995 (n = 9777) Kokkinos et al. 2008 (n= 15,660) 0% 5% 10% Redrawn from: Kokkinos & Myers; Circulation 2010; 122(16): 1637-1648 15%

20% 25% And the winner Kaminsky L A et al. Circulation. 2013;127:652-662 What about Obesity? Wang et al. Lancet 2011; 378 (9793): 812-825.

All-Cause Mortality n = 14,345 Lee D et al. Circulation 2011;124(23): 2483-2490 Obesity Paradox Unfit Fit McAuley et al. Mayo Clin Proc 2010:

85(2):115-121. Medicalize Obesity or Deconditioning? AMA classifies obesity as a disease Did they forget deconditioning? If deconditioning were a recognized syndrome or diagnosis like hypertension, diabetes and POTS, it would be easier to educate the general public and medical community about the one universally effective treatment for it exercise training Dr. Joyner Mayo Clinic Joyner, MJ. J Physiol 2012; 590 (pt 15):3413-4

Effects of Physical Inactivity Cardiorespiratory Fitness Effects of Chronic Exercise Training Components of an Exercise Prescription Individualizing Exercise Prescription Provider Resources Initiative focused on encouraging primary care physicians and health care providers to include exercise into their treatment plans Evidence Pathogenesis STRONG

T2DM, Insulin Resistance Dyslipidemia Hypertension, Obesity COPD Heart Disease/Failure Intermittent Claudication Rheumatoid Arthritis Osteoporosis Fibromyalgia Chronic Fatigue Syndrome Depression Pedersen & Saltin.

Scand J Med Sci Sport 2006;16 Suppl 1: 3-63. MODERATE LIMITED NONE Evidence Symptoms STRONG T2DM, Insulin Resistance

Dyslipidemia Hypertension, Obesity COPD Heart Disease/Failure Intermittent Claudication Rheumatoid Arthritis Osteoporosis Fibromyalgia Chronic Fatigue Syndrome Depression Pedersen & Saltin. Scand J Med Sci Sport 2006; 16 Suppl 1:3-63.

MODERATE LIMITED NONE Evidence Quality of Life STRONG T2DM, Insulin Resistance Dyslipidemia Hypertension, Obesity

COPD Heart Disease/Failure Intermittent Claudication Rheumatoid Arthritis Osteoporosis Fibromyalgia Chronic Fatigue Syndrome Depression Pedersen & Saltin. Scand J Med Sci Sport 2006;16 Suppl 1: 3-63. MODERATE

LIMITED NONE Exercise: The real Polypill Fiuza-Luces C et al. Physiology 2013;28(5):330-358 Exercise as Effective as Drugs

Naci, H and Loannidis, JP. BMJ 2013; 347:f5577 Take-Home Points Any activity is good activity, activity enhancing CRF is best Deconditioning perhaps more than obesity deserves greater attention Exercise IS medicine embrace it Effects of Physical Inactivity Cardiorespiratory Fitness Effects of Chronic Exercise Training Components of an Exercise Prescription

Individualizing Exercise Prescription Provider Resources An Optimal Ex Rx should address: Cardiorespiratory Fitness (aerobic training) Muscular strength and endurance (resistance training) Flexibility Body Composition (ACSM Guidelines for Exercise Testing and Prescription 9 th ed) Prescribing Exercise: The FITT Principle 5 components:

Frequency # of times per week Intensity how challenging Time how long Type modes of exercises Progression change over time A program of regular exercise for most adults should include a

variety of exercise beyond activities performed as a part of daily living. An exercise prescription should include a plan to decrease periods of physical inactivity as well as increasing physical activity. (ACSM Guidelines for Exercise Testing and Prescription 9th ed) FITT Principle Frequency Aerobic Exercise Resistance Exercise

5 days/week of moderate exercise, or 3 days/week of vigorous exercise, or a combination of moderate and vigorous exercise on 3-5 days/week. Each major muscle group should be trained on 2-3 days per week, with at least 48 hours in between sessions. Moderate and/or vigorous intensity is recommended for most adults. Light-to-moderate intensity exercise may be beneficial in most deconditioned individuals. Moderate to vigorous intensity for novice to intermediate

exercisers to improve strength. Vigorous to very vigorous intensity for experienced strength trainers to improve strength. Very light to light intensity for older individuals beginning exercise to improve strength and for previously sedentary individuals beginning a resistance training program. 30-60 minutes/day of purposeful moderate exercise, or 2060 minutes/day of vigorous exercise, or a combination of moderate and vigorous exercise per day. Exercise may be performed in one (continuous) session per day or in multiple sessions of 10 minutes to accumulate the desired duration per day. <20 minutes of exercise per day can be beneficial,

especially in previously sedentary individuals. No specific duration of training has been identified for effectiveness Regular, purposeful exercise that involves large muscle groups and is continuous and rhythmic in nature. Resistance exercises involving each major muscle group are recommended A variety of exercise equipment and/or body weight can be used to perform these exercises.

A gradual progression of exercise volume by adjusting exercise duration, frequency and/or intensity is reasonable until the desired exercise goal (maintenance) is attained. A gradual progression of greater resistance, and/or more repetitions per set, and/or increasing frequency is recommended. Intensity Time Type

Progression (ACSM Guidelines for Exercise Testing and Prescription 9th ed. ) For Important Health Benefits Adults need at least: Frequency: 5 days Frequency: 3 days Intensity: Moderate Intensity: Vigorous intensity intensity Time: 30 minutes

Time: 20-25 minutes Type: Aerobic activity OR Type: Aerobic activity (i.e. brisk walking) (i.e. jogging or running) AND AND Muscle strengthening Muscle strengthening activities on 2 or more activities on 2 or more days a week that work days a week that work

all major muscle groups. all major muscle groups. For even greater health benefits adults should increase their activity to: Frequency: 5-6 days Frequency: 5-6 days Intensity: Moderate Intensity: Vigorous intensity intensity Time: 50-60 minutes Time: 25-30 minutes

Type: Aerobic activity Type: Aerobic activity OR (i.e. brisk walking) (i.e. jogging or running) AND AND Muscle strengthening Muscle strengthening activities on 2 or more activities on 2 or more days a week that work days a week that work

all major muscle groups. all major muscle groups. Effects of Physical Inactivity Cardiorespiratory Fitness Effects of Chronic Exercise Training Components of an Exercise Prescription Individualizing Exercise Prescription Provider Resources Exercise Prescription for Veterans Do physicians prescribe the same medicine for all patients?

Each Veteran is unique One size fits all and off-the-shelf exercise programs are inappropriate Individually tailored programs improve exercise adherence (Cox et al. 2003; Hillsdon et al. 2005; Kahn et al. 2002; Smith & Leon 2003; Marcus et al. 2006; Seguin et al. 2010) Individualizing an Exercise Rx Follow the FITT guidelines. For very deconditioned or novice exercisers beginning at a lighter intensity is beneficial. When progressing an exercise program always

increase Frequency and/or Time BEFORE increasing Intensity. Individualizing an Exercise Rx Ask the Veteran what he/she likes and dislikes about exercise. Focus the program around activities that will be enjoyed and what will help to accomplish his/her goals. Come up with strategies for avoiding relapse and overcoming the common Barriers to Physical Activity. Barriers to Physical Activity

1. 2. 3. 4. 5. 6. 7. 8. No time Not convenient Lacking self-motivation Not fun

Low self-efficacy Fear of injury Lack of encouragement/support Access to equipment Sallis and Hovell 1990; Sallis et al. 1992 Overcoming Barriers to Physical Activity Be active during TV commercials Mark times for physical activity into a personal calendar Join an exercise group

or class When traveling- pack a jump rope, or walk the hotel halls and/or climb the stairs. Take the stairs Park far away Get off the bus/subway a station earlier and walk the remainder Get a dog Get dance fever

Get up to change the TV channel Improving Exercise Adherence Most adults in the United Sates do not engage in the recommended amounts of physical activity. For individuals who choose to engage in an exercise program, greater than 50% will drop out over the first 6 months. (ACSM Guidelines for Exercise Testing and Prescription, 9th ed.) Are we recommending Physical Activity/Exercise?

About 1 in 3 adults who saw a physician or other health care professional in 2010 were advised to begin or maintain exercise or physical activity. Barnes & Schoenborn, NCHS Data Brief, 2012; 86: 1-8 Does it make a difference? Yes. Even simple and brief advice can improve

physical activity levels among adults. Anokye et al. Br J Sports Med 2014; 8: 202-206. Recommendations to Improve Adherence Home-based activities are associated with higher adherence than facility-based activities. Being physically inactive at the start of a prescription is associated with lower adherence. Some form of personal counseling or motivational techniques may be beneficial in addition to an

individualized exercise prescription for those who are previously sedentary. Leijon et al. BMC Family Practice. 2010; 11: 38 Developing an Exercise Prescription: An Example Mr. Jones is a 45 y/o male who has come in for his annual physical. Overweight with a BMI of 29 Currently sedentary No other adverse health conditions Questions to ask Mr. Jones

What are your goals? Are you doing any kind of activity right now? What do you like to do? Do you have a lot of time in your weekly schedule? Are you interested in a program that requires more structure? Or flexibility? Mr. Jones says that he would like to lose some weight and be more active to set a good example for his kids. Other than walking the dog and chasing his kids around he does not do much physical

activity. Works a standard 9 to 5 job, then comes home and cares for his family- time is tight. Prefers to avoid joining a gym to save on time and money. Exercise Prescription: Frequency Aim for 5 to 6 days a week of activity. Combine leisure activities with more purposeful activity such as brisk walking and resistance training. Resistance training can be done 2 to 3 times a week to supplement the walking.

Exercise Prescription: Type Due to time constraints walking is probably Mr. Jones best method for activity. Encourage brisk walking. Encourage Mr. Jones to pursue some easy resistance training in addition to the walking- as this will help with his weight loss goals. A set of resistance tubing is light and compact and can be easily performed in the comfort of ones own home. Most resistance tubing exercises also do not take much more than 20 minutes to complete. Exercise Prescription: Intensity

Brisk walking should be done at a moderate intensity. A good method to monitor this is through the talk test. The talk test is a subjective way of measuring intensity that does not require any skill or equipment. The resistance exercises should feel hard for the duration of the sets. When it becomes easy a heavier resistance will be required. Exercise Prescription: Time Aim for at least 30 minutes of moderate activity on 5 to 6 days a week.

On days when time is an issue break up the 30 minutes into three 10 minute bouts spread out throughout the day. For example- a brisk 10 minute walk after breakfast, a 10 minute walk after lunch, and a 10 minute walk after dinner = 30 MINUTES Effects of Physical Inactivity Cardiorespiratory Fitness Effects of Chronic Exercise Training Components of an Exercise Prescription Individualizing Exercise Prescription Provider Resources

Internet Resources Keys to Exercise Videos: http://exerciseismedicine.org/keys.htm Free Assessment Tools/Custom Exercise Plan: http://www.myexerciseplan.com/assessment/ CDC Physical Activity Videos: http://www.cdc.gov/physicalactivity/everyone/videos/index.html Where to Walk: http://www.walkinginfo.org/

AHA Walking Guide: http://www.startwalkingnow.org/ ACSM Free Health/Fitness Fact Sheets: http://www.acsm.org/access-public-information/brochures-fact-sheets/fact-sheets CDC Weekly Exercise Examples: http://www.cdc.gov/physicalactivity/downloads/pa_examples.pdf Guidelines, Position Stands, Calculators Physical Activity Guidelines: http://www.cdc.gov/physicalactivity/everyone/guidelines/index.html

http://www.health.gov/PAGuidelines/ Dietary Guidelines for Americans: http://health.gov/dietaryguidelines/ NHLBI BMI Calculator http://www.nhlbisupport.com/bmi/ Exercise is Medicine Campaign: http://exerciseismedicine.org/ ACE Fitness Tools & Calculators

http://www.acefitness.org/calculators/default.aspx VA MOVE Program: http://www.move.va.gov/ ACSM Position Stands: http://www.acsm.org/access-public-information/position-stands Pre-Participation Checklist (PAR-Q) 1. Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor? 2. Do you feel pain in your chest when you do physical activity? 3. In the past month, have you had chest pain when you were not doing

physical activity? 4. Do you lose your balance because of dizziness or do you ever lose consciousness? 5. Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity? 6. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition? 7. Do you know of any other reason why you should not do physical activity? **If you answer YES to any of these seek medical opinion first Questions?? References

Agha et al. Are Patients at Veterans Affairs Medical Centers Sicker?: A Comparative Analysis of Health Status and Medical Resource Use . Arch Intern Med 2000; 160(21):3252-3257. Anokye NK, Lord J, Fox-Rushby J. Is brief advice in primary care a cost-effective way to promote physical activity? Br J Sports Med 2014; 48: 202-206. Barnes PM, Schoenborn CA. Trends in adults receiving a recommendation for exercise or other physical activity from a physician or other health professional. NCHS data brief, no 86. Hyattsville, MD: National Center for Health Statistics. 2012; 86: 1-8 Bassett et al. Medical Hazards of Prolonged Sitting. Exerc Sport Sci Rev 2010; 38 (3): 101-2 DeVol & Bedroussian. An unhealthy America: the economic burden of chronic disease. Charting a new course to save lives and

increase productivity and economic growth. http://www.milkeninstitute.org/pdf/ES_ResearchFindings.pdf Ekblom-Bak E, et al. The importance of non-exercise physical activity for cardiovascular health and longevity. Br J Sports Med 2013; 48:233238 Fiuza-Luces C et al. Exercise is the real polypill. Physiology 2013; 28(5):330-358 Garber et al. 2011 Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: Guidance for prescribing exercise. Med Sci Sports 2011; 1332-1359. Handschin C, Spiegelman BM. The role of exercise and PGC1 in inflammation and chronic disease. Nature 2008; 454: 463-469. Joyner, MJ. Standing up for exercise: should deconditioning be medicalized? J Physiol 2012; 590(pt 15): 3413-4 Joyner, MJ & Pedersen BK. Ten questions about systems biology. J Physiol 2011; 1017-30. Kaminsky et al. The Importance of Cardiorespiratory Fitness in the United States: The Need for a National Registry. Circulation. 2013; 127: 652-662 Katzmarzyk & Janssen. The economic costs associated with physical inactivity and obesity in Canada: an update. Can J Appl Physiol 2004; 29 (1), 90-115

Kokkinos P, Myers J. Exercise and physical activity: clinical outcomes and applications. Circulation 2010; 122(16):1637-1648 Lee DC et al. Long-term effects of changes in cardiorespiratory fitness and body mass index on all-cause and cardiovascular disease mortality in Men: The Aerobics center Longitudinal Study. Circulation 2011;124(23): 2483-2490 Lee et al. Mortality trends in the general population: the importance of cardiorespiratory fitness. J Psychopharm 2010; 24:27-35 Lee I-M, Shiroma EJ, Lobelo F, et al. Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy. Lancet 2012; 380: 21929. References(Cont.)

Leijon et al. Factors associated with patients self-reported adherence to prescribed physical activity in routine primary health care. BMC Family Practice 2010; 11:38. Lim et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 19902010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012; 380: 222460 Littman et al. Physical Activity in a National Sample of Veterans. Med Sci Sports Exerc 2009; 41 (5), pp.1006-1013 Liu et al.Cardiorespiratory Fitness as a Predictor of Dementia Mortality in Men and Women. Medicine & Science in Sports & Exercise: 2012; 44 (2): 253259 Maher et al. Reconsidering the sedentary behavior paradigm. PLoS ONE 2014; 9 (1): e86403 Matthews et al. Amount of time spent in sedentary behaviors in the United States, 2003-2004. Am J Epidemiol 2008; 167 (7):875881 McAuley et al. Obesity paradox and cardiorespiratory fitness in 12,417 male veterans aged 40 to 70 years. Mayo Clin Proc 2010:85(2):115-121. Morris, J and Crawford, M. Coronary Heart Disease and Physical Activity of Work. BMJ 1958; 2 (5111): 1485-1496. Myers et al. Exercise capacity and mortality among men referred for exercise testing. N Engl J Med 2002; 346(11):793-801.

Naci, H and Loannidis, JP. Comparative effectiveness of exercise and drug interventions on mortality outcomes: metaepidemiological study. BMJ 2013; 347:f5577 Owen et al. Too Much Sitting: The Population-Health Science of Sedentary Behavior. Exerc Sport Sci 2010. Rev 38:105-113 Partnership to Fight Chronic Disease. http://www.fightchronicdisease.org/facing-issues/about-crisis Pedersen BK, Saltin B. Evidence for prescribing exercise as therapy in chronic disease. Scand J Med Sci Sports. 2006 Feb;16 Suppl 1:3-63. Slentz et al. Effects of the amount of exercise on body weight, body composition, and measures of central obesity: STRRIDE--a randomized controlled study. Arch Intern Med 2004; 164(1): 31-9 The Council of State Governments 2006. Costs of chronic diseases: What are the States facing? www.healthystates.csg.org/NR/ rdonlyres/...4119.../Trends_Alert.pdfSimilar Wang et al. Health and economic burden of the projected obesity trends in the USA and the UK. The Lancet 2011; 378 (9793): 812-825. Wen and Wu. Stressing harms of physical inactivity to promote exercise. Lancet 2012; 380 (9838), pp. 192-193. S01406736(12)60954-4

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