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The Role of Exercise in Medicine Karolinska Institutet November 2, 2010

The Role of Exercise in Medicine Karolinska Institutet November 2, 2010. Steven N. Blair Departments of Exercise Science & Epidemiology/Biostatistics University of South Carolina. Exercise Is a Relatively New Scientific Discipline: It Has Important Foundations in Scandaniva .

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The Role of Exercise in Medicine Karolinska Institutet November 2, 2010

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  1. The Role of Exercise in MedicineKarolinska InstitutetNovember 2, 2010 Steven N. Blair Departments of Exercise Science & Epidemiology/Biostatistics University of South Carolina

  2. Exercise Is a Relatively New Scientific Discipline:It Has Important Foundations in Scandaniva

  3. 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

  4. Articles/Period—Web of SciencePhysical Activity or Physical Fitness and Cardiovascular Disease # of Articles Years

  5. 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

  6. Risk Factors for Stroke in 22 Countries: INTERSTROKE Study Adjusted for age, sex, and region O’Donnell MJ et al. Lancet 2010; 376(9735):112-123

  7. 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 CRF Lee DC, et al. BJSM; pub online April 23, 2010

  8. Aerobics Center Longitudinal Study

  9. Design of the ACLS 1970 More than 80,000 patients 2005 Cooper Clinic examinations--including history and physical exam, clinical tests, body composition, EBT, and CRF Mortality surveillance to 2003 More than 4000 deaths 1982 ‘86 ‘90 ‘95 ’99 ‘04 Mail-back surveys for case finding and monitoring habits and other characteristics

  10. All-Cause Death Rates by CRF Categories—3120 Women and 10 224 Men—ACLS Blair SN. JAMA 1989

  11. Does Changing Cardiorespiratory Fitness Reduce Mortality Risk?

  12. 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

  13. Age-Adjusted Death Rates by Fitness Change Groups, Men, ACLS Blair SN et al. JAMA 1995; 273:1093-8

  14. 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 Risk of Developing Hypertension P for trend <0.01 Fitness Groups Barlow CE et al. Am J Epidemiol 2006; 163:142-50

  15. 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 Prev2009; 18:1111

  16. CRF and Breast Cancer Mortality Odds Ratio 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 p for trend=0.04 Sui X et al. MSSE 2009; 41:742

  17. Activity, Fitness, and Mortality in Older Adults

  18. 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 All-Cause death rates/1,000 PY Age Groups Sui M et al. JAGS 2007.

  19. Physical Activity as Treatment for Chronic DiseaseExercise Is Medicine!

  20. Cardiorespiratory Fitness and Health Outcomes in Various Population SubgroupsSuch as People Who Are Overweight or Obese or Those with Chronic Disease

  21. Cardiorespiratory Fitness, Risk Factors and All-Cause Mortality, Men, ACLS # of risk factors Risk Factors current smoking SBP >140 mmHg Chol >240 mg/dl Cardiorespiratory Fitness Groups *Adjusted for age, exam year, and other risk factors Blair SN et al. JAMA 1996; 276:205-10

  22. CVD Mortality Risk* by Fitness and BMI Categories, 2316 Men with Diabetes, 179 CVD Deaths p for trend <0.0001 p for trend <0.0001 p for trend <0.002 Church TS et al. Arch Int Med 2005; 165:2114 *Adj for age and examination year

  23. Age and exam year adjusted rates of total CVD events by levels of CRF and severity of HTN in 8147 hypertensive men CVD incidence/1000 man-years P <.001 P <.001 P =.048 CRF: Controlled HTN Stage 1 HTN Stage 2 HTN Severity of HTN Sui X et al. Am J Hyptertension. 2007

  24. Multivariate + % Body Fat adjusted HR of All-Cause Mortality by Fitness Groups, ACLS, 2603 Adults 60+ Adjusted HR p for trend <0.001 106 deaths 98 deaths 95 deaths 90 deaths 61 deaths Cardiorespiratory Fitness *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

  25. Joint Associations of CRF and % Body Fat with All-cause Mortality, ACLS Adults 60+ Death rate/1,000 person-years Deaths 151190 29 72 Rates adjusted for age, sex and exam year Sui M et al. JAMA 2007; 298:2507-16

  26. Muscular Strength and Mortality

  27. Thirds of Muscle Strength and Mortality, 8762 Men--ACLS 503 deaths (145 CVD) during average follow-up of 18.9 years Ruiz J et al. BMJ 2008

  28. Strength, Adiposity, and Cancer Mortality Odds of Cancer Death* 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 P for trend=0.003 Thirds of Strength Ruiz J et al. Cancer Epidemiol Biomarkers Prev 2009; 18:1468 *Adj for age, exam yr, smoking alcohol intake, and health status

  29. Attributable Fractions (%) forAll-Cause Deaths40,842 Men & 12,943 Women, ACLS Blair SN. Br J Sports Med 2009; 43:1-2.

  30. Yes, But Those Are Observational Studies, and We Require Randomized Clinical Trial Evidence

  31. Reduction in Risk of Developing Diabetes in Comparison with Controls, DPP 100 *Moderate intensity exercise of 150 min/week; low calorie, low fat diet 80 58% 60 Risk reduction (%) 40 31% 20 0 Lifestyle Intervention* Metformin DPP Research Group. NEJM 2002; 346:393-403

  32. 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 DPP Res Group. Diab Care 2003; 26:2518

  33. LIFE-P SPPB Score P<0.001 mo mo Means estimated from repeated measures ANCOVA adjusted for gender, field center and baseline values J Gerontol Biol Sci Med Sci 2006;61:1157

  34. LIFE-P Serious adverse events J Gerontol Biol Sci Med Sci 2006;61:1157

  35. Exercise Is Medicinewww.exerciseismedicine.orgExercise Is Medicine World Congress Denver, COMay 31-June 2, 2010

  36. What should I do in my clinical practice to promote physical activity?

  37. 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.

  38. 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.

  39. 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.

  40. 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. MSSE2010; 42(9):1632-1638

  41. HR* According to the Number of Positive Health Factors for All-Cause Mortality P for trend <0.001 *Adjusted for age, examination year, hypertension, diabetes, and hypercholesterolemia Byun et al. MSSE2010; 42(9):1632-1638

  42. Physical Activity Interventions in Clinical Practice

  43. 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.

  44. 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.

  45. Where Do We Go from Here?

  46. 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

  47. 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

  48. 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

  49. Using Modern Technology to Promote Healthful Lifestyles

  50. 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

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