Exercise and Disease

1. Exercise and Disease Chapter 26

2. Introduction Exercise places a stress on the body Disease places a stress on the body Regular exercise can help the body deal with the stress of disease Exercise can add additional stress along with the disease

3. Exercise and the Immune System

4. The Immune System Leukocytes (WBC) Granulocytes (namely neutrophils) (60-70%) � Attack viruses and bacteria Lymphocytes (20-25%) T � B � Lead to the production of Immunoglobulin. Antibody refers to an Ig that reacts with a specific antigen (foreign protein) IgA � found in mucosal secretions (e.g. tears, saliva, respiratory fluids IgD IgE IgG � found in serum IgM Natural Killer Cells � Non-specfic, first line of defense Monocytes (15%) Swell to become macrophages

5. The Players White Blood Cells Neutrophils Immunoglobulin Natural killer cells Macrophages Antigens Glutamine

7. Nonspecific Immune Mechanism Phagocytes macrophages Natural killer cells Inflammatory response: macrophages, complements, histamine, bradykinin Antibacterial substances: alpha-interferons Skin: barrier Respiratory tract: filter Stomach Acids Capacity to lower RBC and intestinal fluid

8. Acquired Immune Mechanism Antibody-based B and T-lymphocytes produce antibodies when exposed to an antigen Immunoglobulin A (IgA), D, E, G, and M Cell-based Helper T cells

9. Acute Exercise No longer lasting effects with moderate exercise Open window theory Pedersen and Ullum, Medicine and Science in Sport and Exercise, 26(2):140, 1994 Intense acute exercise often depresses immune function During the time of immunodepression, microorganisms can invade the body thus increasing the risk of infections. This �open widow� of impaired immune function may last from 3 to 72 hours post-marathon

10. Open Window Theory

11. Moderate Exercise Animal studies: Moderate exercise increases antibody levels and longevity Humans: Walking for 45 minutes, 5 times/wk for 15 weeks resulted in half the colds and a 20% increase in Ig of sedentary people

12. Prolong Exercise Peters and Bateman, South African Medical Journal, 64:582, 1983. Incidence of URTI in 150 runners who completed a 56 km marathon. Symptoms of URTI occurred in 33.3% of runners Symptoms lasted 3 days or longer in 80% of those who developed URTI Peters and Bateman, South African Medical Journal, 64:582, 1983. Incidence of URTI in 150 runners who completed a 56 km marathon. Symptoms of URTI occurred in 33.3% of runners compared to 15.3% of controls during the 2-week period following the race. Symptoms lasted 3 days or longer in 80% of those who developed URTI Peters and Bateman, South African Medical Journal, 64:582, 1983. Incidence of URTI in 150 runners who completed a 56 km marathon. Symptoms of URTI occurred in 33.3% of runners compared to 15.3% of controls during the 2-week period following the race. Symptoms lasted 3 days or longer in 80% of those who developed URTI

13. Prolong Exercise Nieman, D.C Journal of Sports Medicine and Physical Fitness, 30:316,1990. Looked at URTI in the 1987 LA marathon. 12.9% of finishers reported URTI during the week following the race 40% of runners reported at least 1 URTI during the 2 months prior to the marathon. Those who trained more than 96 km/week doubled their odds Nieman, D.C Journal of Sports Medicine and Physical Fitness, 30:316,1990. Looked at URTI in 2311 runners 1-week periods before and after the 1987 LA marathon. 12.9% of finishers reported URTI during the week following the race compared to 2.2% of runners who registered but did not participate. 40% of runners reported at least 1 URTI during the 2 months prior to the marathon. Those who trained more than 96 km/week doubled their odds compared to those who trained less than 32 km/wk Nieman, D.C Journal of Sports Medicine and Physical Fitness, 30:316,1990. Looked at URTI in 2311 runners 1-week periods before and after the 1987 LA marathon. 12.9% of finishers reported URTI during the week following the race compared to 2.2% of runners who registered but did not participate. 40% of runners reported at least 1 URTI during the 2 months prior to the marathon. Those who trained more than 96 km/week doubled their odds compared to those who trained less than 32 km/wk

14. Prolong Exercise Berks, L.S. Medicine and Science in Sport and Exercise, 22(2):207, 1990. 3 hour run on a treadmill Natural killer cells were measured before, and 5 min, 1.5hr, 6 hr, and 21 hr post-run. NK activity was lower by 25-46% after 1.5 and 6 hr post-run. Epinephrine elevated at 5 min post-run while cortisol was elevated at 5 min and 1.5 hr post-run Berks, L.S. Medicine and Science in Sport and Exercise, 22(2):207, 1990. 3 hour run on a treadmill averaging 37.2 km and 69.8% VO2max Natural killer cells were measured before, and 5 min, 1.5hr, 6 hr, and 21 hr post-run. NK activity was lower by 25-46% after 1.5 and 6 hr post-run. Epinephrine elevated at 5 min post-run while cortisol was elevated at 5 min and 1.5 hr post-runBerks, L.S. Medicine and Science in Sport and Exercise, 22(2):207, 1990. 3 hour run on a treadmill averaging 37.2 km and 69.8% VO2max Natural killer cells were measured before, and 5 min, 1.5hr, 6 hr, and 21 hr post-run. NK activity was lower by 25-46% after 1.5 and 6 hr post-run. Epinephrine elevated at 5 min post-run while cortisol was elevated at 5 min and 1.5 hr post-run

15. Prolong Exercise Nieman, D.C. International Journal of Sports Medicine, 23:69, 2002. Saliva was collected pre and 5 and 90 min post-race. Saliva immunoglobulin was 34% lower at 5 min and 25% lower at 90 min post-race Runners who experienced URTI during the 15 days following the marathon (17%) had lower IgA at 90 min post-race Nieman, D.C. International Journal of Sports Medicine, 23:69, 2002. Saliva was collected pre and post-race (5 and 90 min) from runners of the 1999 Charlotte Marathon and the 2000 Grandfather Mountain Marathon Saliva immunoglobulin was 34% lower at 5 min and 25% lower at 90 min post-race IgA levels were not influenced by carbohydrate intake, age or gender. Runners who experienced URTI during the 15 days following the marathon (17%) had lower IgA at 90 min post-race Nieman, D.C. International Journal of Sports Medicine, 23:69, 2002. Saliva was collected pre and post-race (5 and 90 min) from runners of the 1999 Charlotte Marathon and the 2000 Grandfather Mountain Marathon Saliva immunoglobulin was 34% lower at 5 min and 25% lower at 90 min post-race IgA levels were not influenced by carbohydrate intake, age or gender. Runners who experienced URTI during the 15 days following the marathon (17%) had lower IgA at 90 min post-race

16. Overtraining Overtraining is associated with elevated levels of corticosteroids (e.g. cortisone) Elevated corticosteroids have a depressive effect on the immune system

17. Summary Acute Exercise Transient changes (increase NK cells, macrophages) that are restore within 24 hours Prolonged Exercise Decrease in NK cells, macrophages �Open Window� for 3 to 72 hours post-exercise 1-2 week period of increased risk for URTI Lower neutrophil Lower IgA

18. Summary Moderate Training Lower rate of URTI Prolong Training Decrease leukocyte number Decrease in NK cell number Decrease neutrophil function Decrease IgA levels Decrease in plasma glutamine levels

19. Mechanisms Heavy exercise causes large increases in epinephrine and cortisol, hormones which are closely associated with immunosuppression Nieman and Berk found that 3 hours of running markedly increased serum cortisol by 59% and remained elevated for 1.5 hours of recovery The increase in cortisol was inversely correlated with a 25-46% decrease in natural killer cell activity in recovery which lasted 6 hours Esoka and Gmunder reported a significant decrease in T cell proliferative response for several hours after a marathon. This would decrease the bodies first line of defense for the immune system and may explain the higher incidence of URTI in marathon runner

20. Mechanisms Stress hormones catecholamines and cortisol Inadequate diet Glutamine and Arginine L-carnitine Essential fatty acids Vitamin B6, Folic acid, and Vitamin E Muscle microtrauma Migration of leukocytes to injured muscle may reduce immune function Psychological stress

21. Viral Infections Viral infections are extremely common and typically attach the upper respiratory tract but some has systemic effects The most common viral groups are rhinovirus, Coxsackle A and D, echovirus, adenovirus, and influenza

22. Viral Infections and Exercise In people with systemic viral infections, the risk of cardiac-related sudden death increase during exercise The Coxsackle virus may invade the heart and increase the risk of arrhythmias and sudden death during exercise Also, studies have shown that exercising with a viral illness may contribute to bacterial meningitis and acute rhabdomyolyis (muscle destruction). Viral illness decrease physical performance and affect muscle structure. Resumption of training after a viral infection: 2-3 days if symptoms were mild and longer for more severe symptoms In general, patients should should rest at least one day for every day of illness.

23. Recommendations Vitamin C (?) Glutamine (?) Consume carbohydrate during exercise Keep other life stresses to a minimum Eat well balanced diet Avoid overtraining Get adequate sleep Avoid rapid weight loss Avoid putting hands to face Avoid sick people Get a flu shot

24. Recommendations Exercising with URTI No if fever, extreme tiredness, muscle aches, swollen lymph glands, etc. Exercise may exacerbate the illness 2-4 weeks of non-exercise

25. Infectious Mononucleosis Caused by the Epstein Barr virus, a member of the herpes group. 95% of college-aged students are exposed to the virus. The acute phase last 5-14 days, and complete recovery takes 6-8 weeks. Highly trained athletes may not achieve pre-illness levels of fitness for up to three months. Vigorous exercise and contact sports should be avoided for a least one month after the illness has ended.

26. Acquired Immune Deficiency Syndrome (AIDS) Over 12 million people worldwide are affected by the human immunodeficiency virus (HIV) HIV causes deterioration in immune function by attacking T helper cells Many people are HIV-positive but have no symptoms People infected with HIV may have milder form of AIDS called AIDS-related complex (ARC) AIDS results in deterioration of nerve and muscle tissues

27. Exercise and the AIDS patient Muscle atrophy, loss of lean body mass, and general metabolic dysfunction are characteristic of AIDS Exercise training can be an important treatment particularly in the early stages HIV-positive: exercise increases CD4 (T helper cells), enhances fitness and fat free weight, and possibly delays symptoms of the disease ARC: exercise increases CD4 cells but to a lesser extent than during HIV-positive stage AIDS: exercise effects are not well understood during this stage Overall, since intense exercise can cause immunosuppression, people with HIV should avoid intense exercise training.

28. Cancer Second leading cause of death 1.2 million cases per year Women � breast then lung Men � prostate then lung 0.5 million deaths per year Most common types of cancer First in men - prostate First in women - breast Second in men & women - lung

29. Cancer Benign - enclosed Malignant � invade other cells Largely an avoidable disease Exercise All-cause cancer risk Colon Breast Prostate

30. All-Cause Cancer Risk & Exercise

31. Colon Cancer & Exercise 10-100% greater risk in inactive men and women Decrease transit time through GI tract Due to an increase vagal stimulation Stronger inverse relationship between resting HR and risk in Persky et al. Less absorption of cancerous agents Increase F-series prostaglandins Improved hormonal regulation

32. Breast Cancer & Exercise Frisch (1987) Less breast cancer in former athletes Thune (1997) Rockhill (1998) No association between physical activity and breast cancer

33. Prostate Cancer & Exercise Of 11 studies... 3 show no relationship 5 show an inverse relationship 2 show a direct relationship Testosterone may have a positive effect Oliveria (1996) 2000-3000 kcal per week Increases insulin and estrogen levels? Hyperinsulinemia may increase cancer risk

34. Other Cancers Lung 5 studies show possible lower risk in active individuals Stomach, Bladder & Pancreas No effect from 4 stuides Digestive system, Thyroid, Lung, Bladder, & Hematopoietic Lower rates in former female athletes

35. Cancer & Exercise Breast cancer maybe through reducing estrogen and altering menstrual cycle Modifying diet, reduce smoking, etc. Reduce body fat Improved hormonal regulation Improved immune system Decrease sympathetic nervous stimulation Better diet and habits

36. Exercise and the Cancer Patient Exercise can help prevent LBM loss Restore previous physical and pyschological quality of life

37. Diabetes Insulin dependent diabetes mellitus (IDDM) Type I Juvenile Non- Insulin dependent diabetes mellitus (NIDDM Type II Adult onset (less so recently) Gestational (temporary) Secondary (pancreatitis, etc.)

38. Glucose Uptake Normal glucose uptake Insulin GLUT-1 and GLUT-4 Effective transport Glucose uptake in diabetes Insulin (Type I) GLUT-1 and GLUT-4 (Type II) Defective transport

39. Hyperglycemia Result of defective uptake Damage to capillaries Increase clot formation Nerve damage Associated with other diseases

40. Exercise Controlled diabetes only Greater than 100 or less than 250 IDDM No help Prevent or limit risk factors NIDDM Reduce insulin resistance Prevent of limit risk factors

41. IDDM In general, rely more on amino acids and lipids for energy Risk of hypoglycemia No gradual increase in insulin Increase glucose uptake during exercise Prevention of hypoglycemia Inject less insulin Inject insulin over non-exercise muscle Eat prior to or during exercise Hyperglycemia inadequate insulin ketosis

42. NIDDM Concern is hyperglycemia Exercise can help by� Reducing hepatic glucose production Increase muscle mass and GLUT-4 activity Increase enzymes Improved blood flow

43. Arthritis 70% of people over age 65 $13 billion/year

44. Osteoarthritis Most common type of arthritis Deterioration of the articular cartilage of joints Due to age, injury, etc Decrease in ROM, to atrophy, to disuse, to adhesions, to further decrease ROM

45. Exercise and Osteoarthritis Prescription Increase ROM and strength Decease body fat None weight baring exercises Effectiveness Framingham study: Increase risk of osteoarthritis particularly with injury Fries (1996) No increase risk to runners Otterness (1998) Sedentary people showed more joint degeneration

46. Rheumatoid Arthritis Autoimmune disease Exercise does not cause it Exercise can help

47. Osteoporosis 25 million people, 80% are women 1.5 million fractures a year At risk older, females Caucasian or Asian, smokers, drinkers, low body weight, sedentary amenorrhea, or early menopause low calcium intake

48. Bone Formation Osteoblasts: increase bone tissue Osteoclasts: decrease bone tissue

49. Prevention of Osteoporosis Achieving maximal bone density Estrogen Dietary calcium and vitamin D 1300 mg/day for 9-18 1000 mg/day for 19-50 1200 mg/day > 50 Weight baring exercises

50. Pulmonary Disorders COPD asthma bronchitis emphysema

51. Emphysema Damaged aveoli Hypoxia Pulmonary vasoconstriction Further hypoxia Increase pressure Right heart failure

52. Emphysema Accessory muscles Chest deformities Difficulty exhaling

53. Chronic Bronchitis Inflammation of lower respiratory tract Cough and SOB Reduced arterial O2

54. Exercise and COPD Greater ventilation due to increase frequency Metabolic limitations due to reduced arterial O2 50% of patients stops GXT due to leg pain

55. Exercise Prescription and COPD

56. Asthma Edema in the walls of the small bronchioles Lead to SOB, wheezing, tightness in the chest, etc. Increase reports of asthma in athletes

57. Exercise Induced Asthma Develops slowly and peaks around 6-8 minutes of exercise Triggers by air pollutions, cold or dry air, stress Prevention: Swimming is good Proper warm-up Medications