Exercise is Medicine: Through the lifespan Carrie A. Jaworski, MD, FAAFP, FACSMDirector of Primary Care Sports MedicineNorthShore University HealthSystemPCSM Fellowship DirectorUniversity of Chicago/NorthShore

I have nothing to disclose…

Objectives♦Understand barriers to physical activity in

females across the lifespan♦Review the benefits of exercise and

physical activity via case-based examples♦ Introduce the concept of “Exercise is

Medicine” and methods of implementation

♦Plato: “Lack of activity destroys the good condition of every human being, while movement and methodical physical exercise save and preserve it.”

♦Thomas Edison: “The doctor of the future will give no medicine but will interest his patients in the care of the human frame, in diet and in the cause and prevention of disease

U.S. Physical Activity GuidelinesFirst ever U.S. guidelines for physical activity were released in Oct 08’Called for Americans age 6 and older to improve their health by exercisingAdults: 150 min per wk of moderate activity or 75 min of vigorousKids: 60 min per day

FACT40,000,000 – 50,000,000 US adults do not meet recommended physical activity requirements

A sedentary nation♦ ~ 36% of American adults are completely

sedentary♦ ~60% are not regularly active at the

recommended level of 30 minutes per day♦About 14% of young people between 12

and 21 years of age report no recent physical activity.

Reasons people give for NOT exercising…♦ Not enough time♦ Not enough energy♦ No one to exercise

with♦ I don’t like exercising♦ Nowhere to exercise♦ It hurts

Contributors to Overall Health Status

Health Burden of Inactivity vs. Smoking♦ One day of being inactive has roughly an

equivalent health burden to smoking 3 cigarettes.♦ So, being inactive for a whole week has equivalent

health burden to smoking a pack of cigarettes.– Do you advise your patients not to smoke?

Khan MK, BJSM May 2010; 6:395

It is killing our kids…♦More Type 2 diabetes in our youth♦ 61% of overweight 5-10 year olds already

have at least one risk factor for heart disease♦ 26% have two or more risk factors

Medical concerns♦ Obesity♦ Diabetes♦ Lipid Disorders♦ Cardiovascular

issues♦ Sleep Apnea ♦ Mental health

issues

Childhood Obesity♦ Obese adolescents have an 80% chance of

becoming obese adults

♦ Almost 30% of U.S. children do not exercise three or more times a week.

♦ Childhood obesity health expenses are estimated at $14 billion annually.

“The Inactivity Epidemic”Poor cardiorespiratory fitness causes more mortality than being overweight or obese Physical inactivity is ranked 6th amongst risk factors for overall burden of disease in North AmericaWHO’s 2004 Global Health Risks data - physical inactivity constitutes the 4th leading cause of death globally– ~3.3 million attributable deaths per year.

2009 study – Physical inactivity is the leading cause of death in the U.S.

Mayo Clinic Proceedings 2013 88, 1446-1461DOI: (10.1016/j.mayocp.2013.08.020) Copyright © 2013 Mayo Foundation for Medical Education and Research

Physical Activity and Chronic Disease

40,842 Men & 12,943 Women, ACLS

*cardio respiratory fitness

Effect of Fitness (CRF) on MortalityAttributable Fractions (%) for

All-Cause Deaths

Blair SN. Physical inactivity: the biggest public health problem of the 21st century. Br J Sports Med 2009; 43:1-2.

CRF and All-Cause Mortality, 4060 Women and Men ≥60 Years of Age, 989 Deaths

Sui X et al. J Am Geriatrics Soc 2007; 55:1940-7

All-cause deaths/10,000 person-years

Rates are age adjusted

Risk Factor 45-64 yearsHazard Ratio (95% CI)

Smoking 1.56 (1.23-1.99)Physical Inactivity 1.40 (1.05-1.87)

BMI ≥30.0 1.35 (0.96-1.89)High BP 1.35 (1.06-1.73)High Cholesterol 1.14 (0.89-1.44)

Diabetes 3.25 (2.04-5.19)Valiyeva E et al. Arch Int Med 2006; 166:985

Lifestyle-related Risk Factors and Risk of Future Nursing Home Admissions; 6462 Adults

Kids who did vigorous or moderate PA > 60 min. on at least 5 days per week

Pate et al., 2002

Physical activity in middle and high school students

CDC 2012

60 min. of vigorous or moderate PA daily by sex

CDC 2012

Study of PA in girls ages 5-12

Janz et al., 2005; Pate et al., 2006b.

What if there was one prescription

that could prevent and treat

dozens of diseases, such as diabetes,

hypertension and obesity?

-Robert E. Sallis, M.D., M.P.H., FACSM, Exercise is Medicine™ Task Force Chairman

What Can I do?

Reasons people give for exercising…. ♦ To lose weight♦ I lack energy♦ I feel out of shape and want to improve my

fitness♦ I want to expand my network of friends♦ My doctor told me to!

• Patients look to their doctor first for advice on exerciseand physical activity (25%).

• Patients turn next to fitness and health web sites (24%).

Survey conducted by ACSM

Why has the medical community neglected exercise as a treatment?♦ Easier for physician to

issue a prescription to reduce BP, cholesterol, glucose or BMI.– Medication adherence is

very low (1 in 6 take meds as prescribed).

– Reliance on pills transfers responsibility for health to doctor resulting in lower patient physical activity.

♦ Widespread belief we cannot change physical activity habits.(USPSTask Force)– Evidence brief counseling

& pedometer programs can increase physical activity.

– We convince patients to take insulin, Coumadin, chemotherapy, etc – why not exercise?

Mayo Clinic Proceedings 2013 88, 1446-1461DOI: (10.1016/j.mayocp.2013.08.020) Copyright © 2013 Mayo Foundation for Medical Education and Research Terms and Conditions

Use of exercise prescription in healthcare

Reasons healthcare providers give for not prescribing exercise

Barriers to Physical Activity Advising in Physicians

Lack of time

Lack of knowledge/training

Excessive documentation requirements

Poor reimbursement/incentives

Lack of system support

Patient non-adherence to the advice

Doctors make a difference!♦ Four out of 10 physicians

(41%) talk to their patients about the importance of exercise, but don’t always offer suggestions on the best ways to be physically active.

♦ Nearly two-thirds of patients (65%) would be more interested in exercising to stay healthy if advised by their doctor and given additional resources

We need to walk the walk…♦Only 40% of US primary Care physicians

and 36% of US medical students meet the 2008 US physical activity guidelines

♦Healthcare providers who are inactive are less likely to prescribe exercise to their patients and are perceived as less credible

Lobelo. Br J of Sports Med, 2009, 43.

Start early, talk often♦Kids and older women are particularly “at

risk” populations♦ Instill habits early to make them last a

lifetime♦Pregnancy is a great time to start amazing

“family habits”

Health benefits of being active…

Exercise 101…♦ Goal of aerobic

exercise 3-5 times per week

♦ Maintain target heart rate– 220-age = max HR– Multiply by 65 to 75%

to get target HR

♦ Strength training 2x/week

♦ Duration of 30 minutes – Build up to this– 3 ten minute sessions is

just as good

Exercise Vital Signs - Flowsheet

© 2012 Epic Systems Corporation. Confidential

Adult: calculate the total for the week

Exercise Vital Signs – FITT Smartphrase

© 2012 Epic Systems Corporation. Confidential

♦ Implemented in the Kaiser Permanent healthcare system in California in 2010

♦ After 1.5 years of implementation, 86%(1,537,798) of all eligible patients had record of the PAVS completed in their EMR

Coleman et al. Med Sci Sports Exerc. Nov 2012

Integration of PAVS at Kaiser Permanente

♦ Physicians were more likely to document exercise in their progress notes during visits where the PAVS was implementedo An increase of 12% of documentation of PA habitso Patients were 14% more likely to report having discussed

exercise with their primary care physiciano 14% increase in providing exercise referrals to patients

Grant et al. J Gen Intern Med. 2014; 29(2).

• The use of the PAVS was also associated with:o More weight loss in overweight and obese patients

in hospitals that used the PAVSo Greater reduction in HbA1c levels in

diabetic patients

Added Benefits of the PAVS

♦ In New Zealand, prescribing physical activity is an integrated part of their health system

o As part of their “Green Prescription”, physicians provide written PA prescriptions to their patients

♦ A written prescription increased the number of people exercising over verbal advice/counseling1

o Written prescriptions also increased PA levels (+32%) to a greater extent than verbal advice/counseling (+17%)

♦ In another study, providing an exercise prescription increased the level of patients engaging in 150 minutes of weekly PA by nearly 10% over the control group2

The Power of Prescribing PA

1- Swinburn et al. Am J Public Health. 1998; 88.2- Elley et al. BMJ. 2003; April 12, vol 326.

♦ In the Spring 2014, Boston announced a program to subsidize bike-sharing memberships for low-income residents, in partnership with Boston Medical Center.

♦ The “Prescribe-a-Bike” program allows doctors at Boston Medical Center to prescribe low-income patients with a yearlong membership to Hubway, a bike-share program, for only $5.

♦ Plans are to initially enroll 100 low-income residents

http://www.bostonglobe.com/metro/2014/03/27/new-program-will-allow-boston-medical-center-doctors-prescribe-bike-sharing-program/zjwfLfCEtAEGfWYxVn4CiN/story html

Bike Prescription Program

Real life examples…

“School is killing me!”♦ 8 year old obese female with behavior

issues and failing grades presents with mom regarding concerns from school about diagnosis of ADHD.

“School is killing me”♦Patient gained significant weight since last

year’s visit♦School issues point to ADHD trend♦Normal exam and labs♦Used to love to dance, but now embarrassed ♦Mom is averse to medications

ADHD

In studies published in the Archives of Clinical Neuropsychology and Attention Deficit Hyperactivity Disorder, kids with ADHD who exercised performed better on tests of attention, and had less impulsivity, even if they weren't taking stimulant medicines.

Theories behind findingsBlood flow: Exercise increases blood flow to the brain. Kids with ADHD may have less blood flow to the parts of their brain responsible for: thinking and planningBlood vessels: Exercise improves blood vessels and brain structure. This helps with thinking abilityBrain activity: Exercise increases activity in parts of the brain related to behavior and attention

The Physical Activity Environment and Academic Achievement in Massachusetts Schoolchildren

Journal of School Health NOV 2017 Volume 87, Issue 12, 932-940.

Physical activity and school performance

Donnelly et al., 2009.

“School is killing me”♦ Discussion about family approach to weight issue♦ Start with fun, family-based activities♦ “Exer-gaming” allowed♦ Added body weight exercises/resistance training♦ Commitment to do after dinner walks♦ She also returned to dance class ♦ Behavior and grades improved!

“The Middle Aged” Woman: 2018♦ Defined as between 40-64♦ Many have put personal health on hold to raise

family, advance career, etc♦ Differences between exposure to exercise and/or

sport in their youth ♦ Large differences in barriers to physical activity

based on geography, ethnicity and socioeconomic status

What we know about exercise with aging ♦ Minimize physiologic changes

associated with typical aging♦ Increases longevity♦ Decreases sequelae of common

diseases♦ Improves mood and lessens risk

of depression♦ Quality of life improves so that

estimated “quality” years are increased by 3.27

Key Benefits Seen in the Aging Athlete♦ Endurance athletes average a 4 to 6 year

advantage in life expectancy♦ Fitness is the best predictor of longevity♦ Fitness is a major NEGATIVE risk factor for

cancer and heart disease♦ Functional losses of aging are reversed♦ Increased strength reduces fall risk♦ Delays dependency by 10 to 20 years

“The Mature Marathoner”

♦A 54 year-old menopausal female who requests assistance after joining a charity-based marathon program. She used to run recreationally in college but has been busy focusing on her career and has not exercised regularly in the last 3 decades.

The “Mature marathoner”♦ Healthy appearing 54-year old♦ No diabetes, CAD, hypertension or arthritis ♦ No significant family history♦ Overweight, BMI = 29♦ No medications, supplements or illicits♦ Review of systems negative for evidence of

cardiopulmonary disease

Exercise prescription for mature athletes♦ Assess patient’s goals and

limitations♦ Determine appropriate

exercise for the patient– Frequency– Intensity– Type– Time

♦ Assess chronic health problems

Exercise prescription for mature athletes♦ Assess for major CV

risk factors– Chol > 240– BP >160/90– Smoker– Diabetes– Family history in

parents or siblings under 55

Exercise prescription for mature athletes♦ Recommendations for graded exercise stress testing

♦ No testing required for Light-to-Moderate programs

♦ Vigorous program (> 60% VO2-max) – Men > 45, women > 55– Patients with known CVD– Patients with 2 or more risk factors or signs for CVD

General recommendations♦Every adult should accumulate 30

minutes or more of moderate intensity physical activity on most, if not all, days of the week

♦Sedentary individuals should build gradually

♦Simplified target heart rate = 220 – age xintensity vs. perceived exertion

General recommendations♦ Progression of exercise

– Initial conditioning phase– Improvement phase– Maintenance phase

♦ Include all aspects of fitness– Cardiovascular– Strength– Flexibility

“Mature marathoner”♦Gradual progression from 5k race 3 months

later to 10k, half marathon and plan for the Disney Marathon over the course of ~ one and a half years

♦Weight loss to BMI of 27♦Did have stress test prior - normal

“The Empty Nester”♦A 43 year-old single mom from a rural

town whose youngest child just graduated from college and is moving out of state. She is obese, has newly diagnosed diabetes and exhibits mild depression that she relates to now being alone for the first time in many years.

“The Empty Nester”♦ She has gained about 20 lbs

over the last 2 decades and is frustrated

♦ Complains of sleep difficulties and sadness– Screening is positive for mild

depression♦ HgbA1C = 7. Would like to be

off her medications/avoid insulin

♦ Physical exam normal

We know that physical inactivity is a factor in the development of mental illness

Therefore….physical activity should be a factor in the care and treatment of mental illness

Depression♦ World Health Organization ranked depression

as 4th leading contributor to global burden of disease • Estimated to reach 2nd by year 2020• Increases risk of chronic medical illness• Medications and psychotherapy limitations

♦ Over $80 billion lost annually due to decreased productivity and associated medical costs

Depression♦ Relationship between

exercise and depression has been studied for decades.

♦ Earlier research with many design flaws

♦ Current research more robust♦ Still need larger scale studies

to gain statistical strength

Depression♦ Meta-analytic findings indicate exercise has a

large impact on depression. Findings include:• Exercise is effective for a variety of patient

subgroups.• Exercise is not significantly different from

psychotherapy or pharmacologic treatment.• Fitness gains not necessary to achieve reduction

in depressive symptoms.

Depression♦ Herring, Puetz, et al conducted a meta-analysis of

the effect of exercise training on depressive symptoms in patients with chronic illness• Exercise training significantly reduced

depressive symptoms• Larger effects seen:

• If baseline depressive sx were higher• If patients met PA recommendations

Depression♦ Teychenne, Ball & Salmon 2008♦ A systematic review of multiple study designs

demonstrated an inverse relationship between overall physical activity levels and the likelihood of depression in adults of all ages.– Short and long durations as well as high and low

frequencies were effective– Unable to conclude on most effective intensity or type

Depression♦ The lack of evidence on

what type of exercise and the amount to prescribe likely limits physician implementation

♦ Newer research attempts to address this evidence gap

Depression♦ Perraton, Kumar and Machotka 2010

• Systematic review of RCTs on exercise parameters in treatment of depression in adults

♦ 14 RCTs with 20 intervention arms• Majority used a supervised aerobic exercise

intervention– Most common parameter was 60-80% of max

heart rate for 30 minutes, 3x per week for 8wks

Depression♦ Type of exercise

• Aerobic is most studied• No significant difference

between aerobic and anaerobic in available studies

♦ Mode of exercise – No clear trend– Allows for individualized

program

Depression♦ Mode of application

• Location• Indoors

• Group vs. Individual• Both effective

• Supervised vs. Unsupervised• Supervised helped with compliance

• Co-Interventions• Half of trials had medication and/or therapy• Exercise can be stand-alone or a concurrent treatment

Depression♦ Intensity frequency and duration

• Anaerobic• Little mention of intensity • Varied range of frequencies/duration

• Aerobic• 60-80% of maximal heart rate• Three 30-minute sessions per week• 8 weeks duration• Lower than published guidelines for fitness or managing obesity• Similar to that for general health

Guidelines♦The National Institute for Health and

Clinical Excellence recommends structured, supervised exercise programs, 3 times per week for 45 to 60 minutes each session for 10-14 weeks to treat mild depression.

Guidelines♦ The Institute for Clinical

Systems Improvement guidelines recommends physical activity for 30 minutes 3 to 5 days per week to decrease symptoms of major depression.

Bottom Line♦Exercise is effective as monotherapy♦Exercise is equal to medication or CBT♦High frequency exercise is better than low

frequency exercise♦The type of exercise dependent on patient

and their “exercise personality”

The “Empty Nester”♦ Patient was comfortable starting with exercise

videos at home that she rented from library♦ Ventured out to community center for group

fitness after first month♦ Improved mood noted at follow up and by patient♦ Hgb A1C – 6, decrease dose of current oral

medication

“The Weak Link”

♦ 62 year old female with concerns that her upper arms and thighs “jiggle” despite her being an active walker her whole life. She also notes that carrying groceries as well as her dancing with her grandkids is becoming a tad more difficult.

“The Weak Link”♦Patient concerned about her “old lady

arms”, asking for help (or plastic surgery)!

♦Normal gait and average speed♦Strength averages 4/5 for extremities♦Decreased muscle tone/bulk in all four

extremities

Muscle and Aging♦ Sarcopenia is defined as a syndrome characterized by

progressive and generalized loss of muscle mass and strength with the risk of adverse outcome, such as physical disability, poor quality of life and death

♦ Characterized by the atrophy of type II fibers, necrosis and reduction of cross-bridging elements between fibers, smaller and fewer mitochondria

♦ By the age of 80 most at or near the minimum level of strength required to rise from a chair.

Mechanism of Sarcopenia

Sarcopenia Research ♦ Chronic Inflammation

– Norman et al. showed that CRP, as an indicator of acute inflammation, was an independent predictor of grip strength even after adjustment for relevant confounders, such as age, gender and body composition.

♦ Nutrition– Tieland et al. showed that 24 weeks of protein supplementation in frail

older adults improved physical performance, that might be attributable to improvements in neuromuscular action or muscle quality.

– Daly et al. showed that 1.3 g protein/kg body weight/day supplementation was effective in enhancing the effects of resistance exercise training on muscle mass and strength in 100 elderly women (60 to 90 years).

Sarcopenia Research♦ Recent interest in a specific myokine, called myostatin, that

seems to be a potential target to prevent sarcopeniadevelopment.

♦ Myostatin negatively regulates skeletal mass and might also be implicated in regulating hepatic production of IGF-1.

♦ Myostatin gene expression is up-regulated in elderly compared to young subjects, and the age-related elevation of myostatinserum levels correlated with muscle mass.

♦ McKay et al. showed that there is an age-related impairment of muscle stem cell function that might be explained by the co-localization with myostatin in older subjects

Myostatin, cont♦ Myostatin inhibition, even partial reductions, increases muscle

mass in adult and older mammals.♦ Myostatin's effects are highly specific to muscle mass.♦ Disrupting myostatin signaling may also positively affect

multiple other age-associated changes, including increased bone mineral density, improved cardiac ejection fraction, and resistance to diet-induced obesity, dyslipidemia, atherogenesis, hepatic steatosis and inflammation.

♦ Myostatin is a highly druggable protein because it is secreted and accessible in the circulation.

Strength Training Effects♦ Performance of muscle cells

can decrease by as much as 40% in older humans

– 3-5% per decade after 30♦ Strength training in the

elderly can improve cell function and slow this decline

♦ Resistance training leads to:– Cell hypertrophy– Increased peak force– Increased contractile velocity– Increase in overall power

♦ Endurance exercise alone may not prevent sarcopenia

♦ Muscle strength and power are the critical components of walking ability

“The Weak Link”♦Explained the value of strength training♦Added a strength training program to her

walking routine♦Started at 2x/week♦Body weight and bands to start♦Advanced to free weights recently as well

as some machines at the YMCA

Parting thoughts…♦With 1,440 minutes in each day, it shouldn't

be that hard to find 30 minutes a day for moderate physical activity…for both us AND our patients”

Discussion…

Useful tools♦Exerciseismedicine.org – Website for EIM.

Handouts for patients, roadmaps, etc♦ACSM.org - ACSM website provides links

to fitness specialists