Physical activity and exercise in CVD … › sitesplus › documents › 986 › Exercise - John...exercise in CVD Preventionexercise in CVD Prevention and Rehabilitationand Rehabilitation

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Physical activity and Physical activity and exercise in CVD Preventionexercise in CVD Preventionexercise in CVD Prevention exercise in CVD Prevention and Rehabilitationand Rehabilitationand Rehabilitation and Rehabilitation

Dr John BuckleyDr John Buckley BPE MSc PhD FBASESBPE MSc PhD FBASESDr John BuckleyDr John Buckley BPE, MSc, PhD, FBASESBPE, MSc, PhD, FBASES

Reader, Applied Exercise Science in HealthReader, Applied Exercise Science in Health

Th k W l PCC GTh k W l PCC GThank Wales PCC GroupThank Wales PCC Group

Thanks Claire, Mark & Sue and the SWCNThanks Claire, Mark & Sue and the SWCN–– How clever to choose the most important How clever to choose the most important

CVD risk factor to begin the dayCVD risk factor to begin the dayg yg y

Material Property JP Buckley Material Property JP Buckley Shrewsbury March 2011Shrewsbury March 2011

The simple messageThe simple messageThe simple messageThe simple messagefor those who now fall asleep for those who now fall asleep

Physical activity is the most Physical activity is the most important CVD risk factorimportant CVD risk factor

6565--70% inactive70% inactive55%55%--65% Hi Lipids65% Hi Lipids55%55% 65% Hi Lipids65% Hi Lipids2525--30% 30% HBPHBP2020--25% Obese25% Obese2020 25% Obese25% Obese2020--25% Smoke25% Smoke55--7% Diabetes7% Diabetes55--7% Diabetes7% Diabetes


Adjusted Relative Risks of CVDAdjusted Relative Risks of CVD for 8 predictorsfor 8 predictorsFarrel et al (1998) Med Sci Sports Exerc; 30 899

3 5

Farrel et al (1998) Med Sci Sports Exerc; 30:899Blair et al (1996) JAMA; 276:205

3.01

2.522 5

3

3.5

sk

n= 25,341 males8 year follow-up

d 43

1.651.34 1 2 1 18

1.7 1.571 5

2

2.5

tive

Ris aged 43 years

1.2 1.18

0.5

1

1.5

Rel

at

0Low Fit Smoking High

CholHigh BP High

BMIFamilyHistory

AbnormECG

ChronicIllnessChol BMI History ECG Illness

Risk of Risk of CVD and a CVD and a Shorter Life!Shorter Life!Rel Risk

2.520 mins/mile15 i / il

Rel Risk

1 5

2 15 mins/mile12mins/mile

1

1.5

0.5

1

0HBP Diabetes Smoking Obesity Hi Cholest

Myers et al., 2002 NEJM; 346: 793

OBESITY Management OBESITY Management –– It’s not just about food! It’s not just about food! Since 1960 an energ gap and noSince 1960 an energ gap and no ChasmChasm has been createdhas been createdSince 1960 an energy gap and now Since 1960 an energy gap and now ChasmChasm has been created has been created between energy consumption and expenditurebetween energy consumption and expenditure

England, 200750%of

ObesityEnergy consumption

Obesity

1960 2005+

Energy expenditure50%

ofObesity

Campbell & Haslam, 2005WHY IS THE DEVELOPED WORLD OBESE? Bleich et al., 2007

FAOSTAT and OECD Health database

W H O D tW H O D tW.H.O. DataW.H.O. DataIn developed countries In developed countries physical inactivity is physical inactivity is

For those with CVD, typeFor those with CVD, type--2 2 diabetes, breast & colon diabetes, breast & colon

responsible for:responsible for:–– 23% of cardiovascular 23% of cardiovascular

diseasedisease

cancercancer–– World over, 40% of these World over, 40% of these

people are inactivepeople are inactivedisease disease –– 17% of colon cancer 17% of colon cancer –– 15% of type 2 diabetes15% of type 2 diabetes

people are inactivepeople are inactive

–– In UK inactivity 70% ofIn UK inactivity 70% ofypyp–– 12% of stroke 12% of stroke –– 11% of breast cancer11% of breast cancer

In UK inactivity 70% of In UK inactivity 70% of these people are inactive these people are inactive

WHO 2002 WHO 2012 - Lee et al, Lancet 380: 219

6565--70% Inactive70% Inactive20112011TargetsTargets

150 150 minsmins/week/week

20112011

//Moderate intensityModerate intensity

7575 minsmins/week/week75 75 minsmins/week/weekVigorous intensityVigorous intensity

or combination of theor combination of theor combination of the or combination of the twotwo

But…But…Those least active, likely Those least active, likely

t b fit ft b fit fto benefit from any to benefit from any regular increase in using regular increase in using

their muscles moretheir muscles more

Ph i l ti it f h lthPh i l ti it f h lthPhysical activity for healthPhysical activity for healthSomewhere between the scourge of sedentary Somewhere between the scourge of sedentary g yg ybehaviourbehaviour and the scourge of high athletic and the scourge of high athletic endeavourendeavour


FFor those of you whoor those of you whoFFor those of you who or those of you who wish to stay awake…wish to stay awake…


S iS i AiAiSession Session AimsAimsAppreciate the reasons why people are inactive Appreciate the reasons why people are inactive and the best possible solutions to reversing the and the best possible solutions to reversing the p gp gepidemic of inactivity epidemic of inactivity (BEHAVIOURAL)(BEHAVIOURAL)

Reflect on the Reflect on the role role physical physical activity plays in activity plays in CVD CVD prevention andprevention and rehabilitationrehabilitation (BIO(BIO--MEDICAL)MEDICAL)prevention and prevention and rehabilitation rehabilitation (BIO(BIO--MEDICAL)MEDICAL)

-- Primordial and InterventionalPrimordial and Interventional


S i bj tiS i bj tiSession objectivesSession objectives

To highlight To highlight the independent the independent effects of: effects of: –– Anything that leads to avoiding Anything that leads to avoiding sittingsitting–– Anything that leads to expending > 1000 kcalsAnything that leads to expending > 1000 kcals//wkwk–– Anything that increases aerobic Anything that increases aerobic fitnessfitness

Think Think behaviourbehaviour first!first!


Therefore……!!!!!Therefore……!!!!!

Fixing the problem is not just simply Fixing the problem is not just simply getting people to do more exercise; it is getting people to do more exercise; it is a complex combination of total body a complex combination of total body p yp ymovements from the time of wakingmovements from the time of waking--up up to the time of goingto the time of going sleepsleepto the time of going to the time of going sleepsleep


Gearing people up to beneficial levels ofGearing people up to beneficial levels ofGearing people up to beneficial levels of Gearing people up to beneficial levels of weekly weekly energy expenditureenergy expenditure


TheThe Gears of total energy expenditureGears of total energy expenditureThe The Gears of total energy expenditureGears of total energy expenditure(the dose of weekly physical activity) (the dose of weekly physical activity)

1.Standing

l l

1.Standing

l l

3.Human

3.Human REVERSEREVERSE

SittingSittingREVERSEREVERSE

SittingSitting -Low level basal human

activity

-Low level basal human

activity

transporttransportSittingSittingSittingSitting

4.4.Active leisure, Active leisure, exercise and exercise and


2.Occupational

domestic

2.Occupational

domestichealth health

sessionssessionshealth health

sessionssessions

domestic activity

domestic activity


TheThe Gears of total energy expenditureGears of total energy expenditureThe The Gears of total energy expenditureGears of total energy expenditure(the dose of weekly physical activity) (the dose of weekly physical activity)

1.Standing

l l

1.Standing

l l

3.Human

3.Human REVERSEREVERSE

SittingSittingREVERSEREVERSE

SittingSitting -Low level basal human

activity

-Low level basal human

activity

transporttransportSittingSittingSittingSitting



2.Occupational

domestic

2.Occupational

domestic

Are Are prevention prevention and rehab’ and rehab’

Are Are prevention prevention and rehab’ and rehab’

health health sessionssessionshealth health

sessionssessions

domestic activity

domestic activity

programmesprogrammestoo focused too focused

here?here?

programmesprogrammestoo focused too focused

here?here?


In people who are activeIn people who are active(150 (150 minsmins/week)/week)

From where do they get From where do they get their weekly doses?their weekly doses?yy


Using your clutch correctly to prevent grinding of the gears!Using your clutch correctly to prevent grinding of the gears!To effectively engage with your patient/client you To effectively engage with your patient/client you need to clear three important hurdlesneed to clear three important hurdles

1.1. Assess you own Assess you own behaviourbehaviour

2.2. AvoidAvoid talking at crosstalking at cross--2.2. Avoid Avoid talking at crosstalking at crosspurposespurposes

1.1. Appreciate the Appreciate the nuances of physical nuances of physical activity activity behaviourbehaviour


Th fi t h dlTh fi t h dlThe first hurdleThe first hurdle

Get off your butts yourself!Get off your butts yourself!


B h i ll tiB h i ll ti lf!lf!Be physically active Be physically active yourself!yourself!

GPs and Practice Nurses, whoare regularly active, are 3 to 4 a e egu a y a e, a e 3 otimes more effective at promoting physical activity in their patients…

McDowell et al (1997) BJSM 31: 308 – 313McKenna et al (1998) BJSM 32: 242 – 247


ThTh dd h dlh dlThe The secordsecord hurdlehurdleA id lkiA id lki ??Avoid talking at crossAvoid talking at cross--purposes?purposes?

Clarify with your patients what you Clarify with your patients what you b th d t d b th tb th d t d b th tboth understand by the terms:both understand by the terms:–– Physical activity, Exercise, Sport, FitnessPhysical activity, Exercise, Sport, Fitness


Regardless of profession, we are all Regardless of profession, we are all physicalphysical activity counsellorsactivity counsellorsphysical physical activity counsellorsactivity counsellors

How would you feel ifHow would you feel ifyour smoking cessationyour smoking cessationyour smoking cessation your smoking cessation counsellor was a smoker?counsellor was a smoker?


Thi d h dlThi d h dlThird hurdleThird hurdle

Remember physical activity is a Remember physical activity is a behaviourbehaviour influenced by psychological influenced by psychological and social determinantsand social determinants

Th l i i bi di lTh l i i bi di lThe solution is not biomedicalThe solution is not biomedical


B h iB h iBehaviourBehaviourThe science and physiology is a waste of time The science and physiology is a waste of time if we can’t get people to do it!if we can’t get people to do it!

An agreeable dose of activity and the socialAn agreeable dose of activity and the socialAn agreeable dose of activity and the social An agreeable dose of activity and the social and environmental factors in which it is and environmental factors in which it is performed are key to enjoyment/adherenceperformed are key to enjoyment/adherenceperformed are key to enjoyment/adherenceperformed are key to enjoyment/adherence



The same physical The same physical activity situation can be activity situation can be

i ll di ll dsocially and socially and psychologically psychologically

attractive for one butattractive for one butattractive for one but attractive for one but the opposite for the opposite for

anotheranother


Assess and advise your patient by Assess and advise your patient by checking performance in each of the checking performance in each of the behaviouralbehavioural gearsgearsgg

Get people simply to stand upGet people simply to stand upAdd ti it i d t d lifAdd ti it i d t d lifAdd more activity in day to day lifeAdd more activity in day to day lifeParticipating in fitness gaining physical Participating in fitness gaining physical p g g g p yp g g g p yactivity, exercise and/or sportactivity, exercise and/or sport


Getting out of reverseGetting out of reverseGetting out of reverse Getting out of reverse into 1into 1stst GearGear


Energy expenditure atEnergy expenditure atEnergy expenditure at Energy expenditure at low level basal activitylow level basal activity

Body position Energy requirements (kcal/min)

Levine et al 2000 Am J Clin Nutr 72 (6): 1451 - 54

Body position Energy requirements (kcal/min)Lying 1.30Sitting still 1 33Sitting still 1.33Sitting fidgeting 2.00 (54% increase over sitting/lying still)

St di till 1 46Standing still 1.46Standing fidgeting 2.50 (92% Increase over sitting/lying still)


The “walk and work” desk!The “walk and work” desk!Levine and Miller Levine and Miller 2007 Br J Sports Med 41(9):558-61



Writing and travelWriting and travel broaden your ass if not your mind and I like toyour mind and I like to

write standing up

Hemingway, 1950


EDUCATION & FAMILY9 January 2013 Last updated at 01:27

Stand up at office to lose weight says exercise scientistStand up at office to lose weight, says exercise scientist

Office workers trapped behind their desks all day should push away their chairs and work standing up, recommends anexercise scientist.

By Sean CoughlanBBC News education correspondent

exercise scientist.

Standing up for three hours extra a day would burn off 8lb (3.6kg) of fat each year, says John Buckley, from the University ofChester.

Leading by example, Dr Buckley is using a standing desk which is believed to date from the 1940s.

"There is no need to sit down so much," says Dr Buckley.

Anyone feeling Christmas-pudding shaped after the holidays should consider standing rather than sitting at work, says Dr Buckle

There are custom-made computer desks for anyone wanting to stand as they answer their emails - or else old desks can be setheight for standing.

Upright languageThis upright stance was championed by Ernest Hemingway, whose vigorous prose was matched by this more physical approachThis upright stance was championed by Ernest Hemingway, whose vigorous prose was matched by this more physical approachwriting.

"Writing and travel broaden your ass if not your mind and I like to write standing up," wrote Hemingway in a letter in 1950.

Vladimir Nabokov was another writer who preferred to stand.

Dr Buckley, from the department of clinical sciences and nutrition, says that switching from chairs to working standing up will redobesity and improve circulation.

Standing up for three hours will consume 144 calories, he says.



The cardiovascular and The cardiovascular and metabolic benefits of metabolic benefits of standing desk workstanding desk work

Buckley et al., Unpublished, April, 2013Buckley et al., Unpublished, April, 2013

M th dM th dMethods: measuresMethods: measures

Ergotron adjustable desk Timex HR monitor Technogym movement monitor

Animas continuous BG monitor Cortex Metalyser, respiratory analysis system

Fig.2 Heart Rate and Calories expended per minute

95

100Seated vs Standing Work

StandingHR avg = 89

Cals/min = 3.3

85

90

SeatedHR avg = 79

C l / i 2 6

75

80

Cals/min = 2.6

65

70

55

60

50

12 1pm 2pm 3pm 4pm 5pm

6Results – continuous glucose monitoring

5

6

Change Day 1 (seated)

Change Day 2 (Standing)

/l) g g

3

4

se (

mm

ol/

1

2

n G

luco

s

0

1

Chan

ge i

-2

-1

5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 00 05 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85

C

1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 9 9 10 10 11 11 12 12 13 13 14 14 15 15 16 16 17 17 18 18

Time (mins) from standardised lunch to end of working day

Fig 3 Change in blood glucose following a standard buffet lunch whilst workingFig 3. Change in blood glucose, following a standard buffet lunch, whilst working predominantly for 185 mins in a seated or standing position (n=10)

Sitting and knowledgeSitting and knowledge--based workbased workChaput & Trembley Physiol Behav 2007 30;90(1):66 72Chaput & Trembley Physiol Behav. 2007 30;90(1):66-72

Sedentary computer work increases hunger!Sedentary computer work increases hunger!


Metabolic “stunning” from TV in childreng- 211 kcal/day compared to sittingKleseges et al., 1993 Pediatrics 91 (2): 281 - 286


Let’s move up to 2nd gear Let’s move up to 2nd gear i i h i li i h i lincreasing physical increasing physical activity in ADLs at homeactivity in ADLs at homeactivity in ADLs, at home activity in ADLs, at home and workand workand workand work


A Historical rationaleA Historical rationaleA Historical rationaleA Historical rationale

Hippocrates (400 BC)Hippocrates (400 BC)Hippocrates (400 BC)Hippocrates (400 BC)“Eating alone will not keep a man well; he must also

exercise For food and exercise while possessingexercise. For food and exercise, while possessingopposite qualities, yet work together to produce health”

……

And it is necessary, as it appears, to discernthe power of various exercises, both natural (ADLs) and

Artificial (rec’n exercise/sport) to know which of themArtificial (rec n, exercise/sport), to know which of them tends to increase flesh (muscle) and which lessen it (fat)…also

proportion exercise to the bulk of food…p p

1953 1953 11stst time in historytime in history11stst time in history time in history

scientifically scientifically provenprovenPhysical activity, Physical activity,

i d bii d biexercise and aerobic exercise and aerobic fitness linked fitness linked to to CVD; CVD;

bik b dbik b d b ffib ffiBuses, bikes, boats and Buses, bikes, boats and boffinsboffins!!


Famous Harvard AlumniFamous Harvard Alumni BoffinsBoffinsFamous Harvard Alumni Famous Harvard Alumni BoffinsBoffinsTheThe WinklevossWinklevoss twinstwins


Morris et Morris et al. Coronary heart disease and physical activity of work. Lancet al. Coronary heart disease and physical activity of work. Lancet

19531953;265(6795):1053;265(6795):1053--11201120 Heady Morris RaffleHeady Morris Raffle Phy-sique of LondonPhy-sique of London19531953;265(6795):1053;265(6795):1053--1120.1120. Heady, Morris, Raffle. Heady, Morris, Raffle. Phy-sique of London Phy-sique of London

busmen: Epidemiology of uniforms. Lancet busmen: Epidemiology of uniforms. Lancet 19561956;271; 569;271; 569--570.570.

MorrisMorris et al. Incidence and prediction ofet al. Incidence and prediction of ischaemicischaemic heartheart--disease in Londondisease in LondonMorris Morris et al. Incidence and prediction of et al. Incidence and prediction of ischaemicischaemic heartheart disease in London disease in London

busmen. Lancet busmen. Lancet 19661966;2;553;2;553--559.559.

PaffenbargerPaffenbarger et al. Work activity of longshoremen as related to death from et al. Work activity of longshoremen as related to death from

coronary heart disease and stroke. N coronary heart disease and stroke. N EnglEngl J Med J Med 1970;1970;282:1109282:1109--1114.1114.

Morris et al. Vigorous exercise in leisureMorris et al. Vigorous exercise in leisure--time and the incidence time and the incidence of coronary of coronary

19731973heartheart--disease. Lancet disease. Lancet 19731973;1: 333;1: 333--339.339.

PaffenbargerPaffenbarger. . Work activity and coronary heart mortality. N Work activity and coronary heart mortality. N EnglEngl J Med J Med

19751975;292:545;292:545--550.550.

Thi d GThi d GThird GearThird Gear

Muscles for transportMuscles for transport


19601960 2010; a2010; a decline of 175 kcals/daydecline of 175 kcals/day19601960 –– 2010; a 2010; a decline of 175 kcals/day decline of 175 kcals/day in energy expenditure at workin energy expenditure at work

Church et al. 2011 PLoS ONE 6(5): e19657. doi:10.1371/journal.pone.0019657

Decline in walkingDecline in walkingggFox & Fox & HilsdonHilsdon (2007) Obesity reviews: 8 (Sup.1): 115(2007) Obesity reviews: 8 (Sup.1): 115––121121

1975:1975: 255 miles/year = 25,500 255 miles/year = 25,500 kcalskcals2003: 2003: 192 miles/year = 19,200 kcals192 miles/year = 19,200 kcals/y ,/y ,

–– Add the 175 kcals/day lost in occupational Add the 175 kcals/day lost in occupational dd e 5 a s/day os o upa o add e 5 a s/day os o upa o awork since 1960 work since 1960

Total = 200 kcals/day lostTotal = 200 kcals/day lostTotal 200 kcals/day lostTotal 200 kcals/day lostnot from lack of sport or exercisenot from lack of sport or exercise45 000 kcals/year = 1 stone of fat45 000 kcals/year = 1 stone of fat45,000 kcals/year = 1 stone of fat45,000 kcals/year = 1 stone of fat

How much reminding is required to How much reminding is required to k l b ti ?k l b ti ?make people be more active?make people be more active?

Blamey et al 1995 Blamey et al 1995 BMJBMJ 311: 289 311: 289 -- 290290

Poster campaign to take stairs vs escalatorPoster campaign to take stairs vs escalator% Improved% Improved

P tP t P tP tover over baselinebaseline 1515

PosterPosterUpUp

PosterPosterWithdrawnWithdrawn

1010

55

5 10 15 weeks after5 10 15 weeks after


Sad but true, most people’sSad but true, most people’sSad but true, most people s Sad but true, most people s physical activity occurs herephysical activity occurs here

Watson, R. and Benelam, B. (2012), Physical activity: the Watson, R. and Benelam, B. (2012), Physical activity: the latest on its contribution to energy balance and health. latest on its contribution to energy balance and health. Nutrition Bulletin 37: 78Nutrition Bulletin 37: 78 85 doi: 10 1111/j 146785 doi: 10 1111/j 1467Nutrition Bulletin, 37: 78Nutrition Bulletin, 37: 78––85. doi: 10.1111/j.146785. doi: 10.1111/j.1467--3010.2011.01953.x3010.2011.01953.x

Physical activity as aPhysical activity as aPhysical activity as a Physical activity as a means of transportmeans of transport

Man and his bike, the most efficient machine everefficient machine ever made biologically and mechanically~25% efficiency~25% efficiency

Automobile - ~20%

S.S. Wilson (March 1973). "Bicycle Technology". Scientific American.

P. Pietro, "Cycling on Earth, in Space, on the Moon," European Journal of


Applied Physiology 82, 345 (2000).

London cycling campaign comparison to London cycling campaign comparison to Netherlands; transport by bicycleNetherlands; transport by bicycleNetherlands; transport by bicycleNetherlands; transport by bicycle

Netherlands: 22% Netherlands: 22% –– 36%36%UK average 2%UK average 2%UK average 2%UK average 2%


Changes in transport Beijing (1986 to 2003)B kl & D h t 2008B kl & D h t 2008Buckley & Doherty 2008 Buckley & Doherty 2008 Adapted Adapted from from PengPeng, 2005; Wang et al., 2006, 2005; Wang et al., 2006

70

60

70Baseline yearFollow-up

40

50

tage

p

30

40

Perc

ent

10

20

P

0Bicycle Public Private Obesity CVD

(1986 - 2000) Transport (1986 - 2000)

Car/Work's bus(1986 - 2000)

(1992-2002) (1993 - 2003)Material Property JP Buckley Material Property JP Buckley

Shrewsbury March 2011Shrewsbury March 2011

K MK MKey Message Key Message Real effects on population physicalReal effects on population physicalReal effects on population physical Real effects on population physical activity levels must include finding activity levels must include finding

f “f “ ” h b l” h b lways of “reways of “re--engineering” the built engineering” the built environment (perhaps by stealth) to environment (perhaps by stealth) to (p p y )(p p y )put PA back into daily livesput PA back into daily lives

Durand et al 2011 Durand et al 2011 Obes RevObes Rev. Feb 23. [Epub ahead of print]. Feb 23. [Epub ahead of print]Frank & Frank & KavageKavage 2009 2009 J Phys Act HealthJ Phys Act Health; 6 ; 6 SupplSuppl 2:S1862:S186--95.95.GordonGordon--Larsen et al. 2005 Larsen et al. 2005 Obes Res ;13(5) 868;13(5) 868--75. 75. AssociationsAssociationsamong active transportation, physical activity, and weight status….among active transportation, physical activity, and weight status….


44thth Gear! Purposeful plannedGear! Purposeful planned44 Gear! Purposeful planned Gear! Purposeful planned physical activity and exercisephysical activity and exercise



Blair et al. 1992 Med Ex Nutr Health; 1:54 –7.

Ph i l ti itPh i l ti it b h ib h iPhysical activity Physical activity behaviourbehaviour

Resources, environment, motivators for Resources, environment, motivators for “getting“ people active “getting“ people active ((e.g. medical event or e.g. medical event or risk identification)…risk identification)…

may be quite different than for thosemay be quite different than for those….may be quite different than for those ….may be quite different than for those “keeping” people active (psycho“keeping” people active (psycho--social)social)


Adhering to planned Adhering to planned g pg pphysical activity/exercisephysical activity/exercise

Enjoyment and satisfaction of physical activity is Enjoyment and satisfaction of physical activity is as influential in uptake and adherence as as influential in uptake and adherence as ppmotivational motivational behaviourbehaviour change strategies change strategies

Intensity “dose” of activity greatly influences Intensity “dose” of activity greatly influences enjoyment/mood enjoyment/mood

Thurston Thurston & Green & Green 2004 2004 Health Health Promot IntPromot Int;19 (3):379;19 (3):379--8787R &R & P fittP fitt 20002000 M d S i S t EM d S i S t E 40(10) 185240(10) 1852 6060Rose & Rose & ParfittParfitt 2000 2000 Med Sci Sports Exerc.Med Sci Sports Exerc. ;40(10):1852;40(10):1852--60.60.


The ideal is if we can get people to The ideal is if we can get people to g p pg p ptake up and “stick at” fitness take up and “stick at” fitness promoting activity????promoting activity????promoting activity????promoting activity????


Relative Risk ofRelative Risk of CVDCVD (primary prevention)(primary prevention)Relative Risk of Relative Risk of CVD CVD (primary prevention)(primary prevention)

Physical activity Physical activity vsvs Aerobic FitnessAerobic Fitness

Williams et al 2001 Med Sci Sport Exerc 33:754-761Material Property JP Buckley Material Property JP Buckley Shrewsbury March 2011Shrewsbury March 2011

Project Active: 24 month randomised trial;Project Active: 24 month randomised trial;Project Active: 24 month randomised trial; Project Active: 24 month randomised trial; Lifestyle vs Structured ActivityLifestyle vs Structured ActivityDunn et al. Dunn et al. JAMAJAMA 1999; 281: 3271999; 281: 327--334334

Aerobic Fitness (VOAerobic Fitness (VO2 peak2 peak ml/kg/min)ml/kg/min)


Project Active 24 month randomised trial;Project Active 24 month randomised trial;Project Active 24 month randomised trial; Project Active 24 month randomised trial; Lifestyle vs Structured ActivityLifestyle vs Structured ActivityDunn et al. Dunn et al. JAMAJAMA 1999; 281: 3271999; 281: 327--334334

Energy expenditure (kcal/kg/day)Energy expenditure (kcal/kg/day)


Exercise Capacity Following Myocardial InfarctionCarson et al (1982) J R Coll Phys, 16 (3), 147-151

20

181920

time) Physiology Psycho-sociology

1617

man

ce (t

Exercise Group

131415

se P

erfo

r

Control Group

111213

Exer

cis Co t o G oup

10Day of M.I. 6 wks 5mnth 1yr 2yrs 3 yrs

Time period post-M.I.


Rehabilitation andRehabilitation andRehabilitation and Rehabilitation and secondary preventionsecondary prevention

Starts with Starts with behaviourbehaviour and educationand education



HHistory shows 30istory shows 30 minsmins/day (150 min/week)/day (150 min/week)HHistory shows 30 istory shows 30 minsmins/day (150 min/week) /day (150 min/week) is nothing new!is nothing new!


In 1772: “I knew of one who set himself the task of sawing wood for half an hour every day, and was nearly cured”


17681768 –– HeberdenHeberden highlighted bothhighlighted both1768 1768 HeberdenHeberden highlighted both highlighted both physical and psychological physical and psychological elements of elements of chest discomfort; called Angina Pectorischest discomfort; called Angina Pectorischest discomfort; called Angina Pectoris chest discomfort; called Angina Pectoris

1772 1772 –– HeberdenHeberden, 1, 1stst cure for angina; cure for angina; reducing symptoms and “worry” throughreducing symptoms and “worry” throughreducing symptoms and worry through reducing symptoms and worry through regular exercise regular exercise (30mins/day)(30mins/day)


“ If the Olympic Games that “ If the Olympic Games that modern Greece has not yet modern Greece has not yet been able to revive still been able to revive still survives today it is due notsurvives today it is due notsurvives today it is due not survives today it is due not to a Greek, but to Dr. W.P. to a Greek, but to Dr. W.P. BrookesBrookes.... my oldest friend!”my oldest friend!”Father of Modern Olympics yy

Baron Pierre de CoubertinBaron Pierre de Coubertiny p

Letter to Letter to Parliament, 4th Parliament, 4th June, 1890June, 1890The school attendance is usually 3 The school attendance is usually 3 h h d 2h h d 2 1/21/2 hhhours in the morning and 2 hours in the morning and 2 1/2 1/2 hours hours in the afternoon. This would leave in the afternoon. This would leave time to devotetime to devote half an hour a dayhalf an hour a daytime to devotetime to devote half an hour a day half an hour a day to bodily trainingto bodily training......


Cardiac RehabilitationCardiac RehabilitationCardiac Rehabilitation Cardiac Rehabilitation WHO (1993)WHO (1993)

“The sum of activities required to influence “The sum of activities required to influence favourably the underlying cause of thefavourably the underlying cause of thefavourably the underlying cause of the favourably the underlying cause of the disease so that (people) disease so that (people) may, by their may, by their own efforts preserve or resume own efforts preserve or resume when when pplost, as normal a place in the community…lost, as normal a place in the community…

= Patient= Patient--centred health behaviour approachcentred health behaviour approach


P ti tP ti t t d ht d hPatientPatient--centred approachcentred approach

BACPR 2012/2013BACPR 2012/2013: don’t just look at : don’t just look at physiological and physical morbidity andphysiological and physical morbidity andphysiological and physical morbidity and physiological and physical morbidity and mortality benefits of CRmortality benefits of CR

–– QoLQoL, good psycho, good psycho--social functioning, selfsocial functioning, self--management is what the patient wants and needsmanagement is what the patient wants and needsmanagement is what the patient wants and needsmanagement is what the patient wants and needs

–– Reduced hospital admissions and reReduced hospital admissions and re--admissions isadmissions is–– Reduced hospital admissions and reReduced hospital admissions and re--admissions is admissions is what the NHS wants and needswhat the NHS wants and needs



20002000 200420042000 2000 -- 20042004

We can now evidence We can now evidence Heberden’sHeberden’s(1772) 30 min dose, physiologically (1772) 30 min dose, physiologically and psychologicallyand psychologicallyp y g yp y g y

h hi hh hi hthe more things change the more things change the more they stay the same!the more they stay the same!the more they stay the same!the more they stay the same!


Four weeks exercise training enhances endothelial vasodilatation in CHD patients (Nitric Oxide)H b ht t l NEJM 2000 342 454 460 Hambrecht et al. NEJM 2000; 342: 454-460, Gielen S, Hambrecht R. Cardiol Clin 2001;19(3):357-68Hambrecht et al Circulation 2003 Jul 1;107(25):3152-8.

Moderate regular exercise Moderate regular exercise vsvs PCIPCIggHambrecht Hambrecht et al Circulationet al Circulation. 2004 Mar 23;109(11):1371. 2004 Mar 23;109(11):1371--88

Event-free survival 88% Exercise (~£1600) 70% PCI ( £3000)70% PCI (~ £3000)


E i t ’ PCIE i t ’ PCIExercise: nature’s PCIExercise: nature’s PCI

FourFour--weeks exercise training is weeks exercise training is nature’s angioplasty!nature’s angioplasty!

Hambrecht et al Hambrecht et al CirculationCirculation. 2004 Mar 23;109(11):1371. 2004 Mar 23;109(11):1371--88

Continuing exercise beyond fourContinuing exercise beyond fourContinuing exercise beyond fourContinuing exercise beyond four--weeks is nature’s stent!weeks is nature’s stent!

TinkenTinken et al 2008 et al 2008 J J PhysiolPhysiol 15; 586 (15; 586 (PtPt 20): 5003 20): 5003 –– 1212


Light exercise & anginaLight exercise & anginaLight exercise & anginaLight exercise & anginaLewin RJ, Furze G, Robinson J Lewin RJ, Furze G, Robinson J et al.et al.Br J Gen Pract 2002;52(476):194Br J Gen Pract 2002;52(476):194––6, 6, 199199––201.201.; ( ); ( ) ,,

Significant reductions in:Significant reductions in:S tS tSymptoms Symptoms Anxiety and depressionAnxiety and depressiony py pFrequency of angina Frequency of angina

ffUse of GTNUse of GTNPerceived physical limitationsPerceived physical limitationsPerceived physical limitationsPerceived physical limitations


l i / i fl i / i fHalting/regression of CHDHalting/regression of CHD

1000 k l/ k d1000 k l/ k d>1000 kcal/week dose>1000 kcal/week dose

Early commencement Early commencement HaykowakyHaykowaky et al 2011et al 2011 MetaMeta analysis of 31analysis of 31 RCTsRCTsHaykowaky Haykowaky et al., 2011 et al., 2011 MetaMeta--analysis of 31 analysis of 31 RCTsRCTsEvery Every one week one week delay delay postpost--MI, MI, in commencing in commencing exercise meansexercise means an extraan extra monthmonth of training toof training to benefitbenefitexercise, means exercise, means an extra an extra month month of training to of training to benefit benefit ventricular ventricular remodeling remodeling


Physical activityPhysical activity and CHD regressionand CHD regressionPhysical activityPhysical activity and CHD regressionand CHD regression

2500

1500

2000

wee

k

Progression

1000kcal

/w No ChangeRegression

0

500

Adapted from Hambrecht et al. 1993 Adapted from Hambrecht et al. 1993 JACCJACC 22: 468 22: 468 –– 477477ppMaterial Property JP Buckley Material Property JP Buckley

Shrewsbury March 2011Shrewsbury March 2011

SummarySummarySummarySummarySStanding up more has significant impact on CVDtanding up more has significant impact on CVD

Use your legs more as a means of transport Use your legs more as a means of transport –– the the li l bi f i dd h b fili l bi f i dd h b filittle bits of extra time add up to much benefit over little bits of extra time add up to much benefit over the longer term; the longer term; “every little helps”“every little helps”

The best evidence is for activities that lead to The best evidence is for activities that lead to improvements in fitness but these have the greatestimprovements in fitness but these have the greatestimprovements in fitness but these have the greatest improvements in fitness but these have the greatest behaviouralbehavioural challenges (<30% population do this!)challenges (<30% population do this!)

AND LISTEN to the Good DoctorAND LISTEN to the Good Doctor



Positive feedbackIs the key toIs the key to over-coming the challenge of inactivity


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