EXERCISE IN PREVENTION AND MANAGEMENT OF DISEASE

Dr Louis HoltzhausenDivision Sport and Exercise Medicine

SPORT AND EXERCISE MEDICINE

• Medical care of the athletic population

SPORT AND EXERCISE MEDICINE

• Rehabilitation of chronic diseases of lifestyle– Cardiac– Pulmonary– Metabolic

SPORT AND EXERCISE MEDICINE

• Prevention of chronic diseases of lifestyle– Cardiac– Pulmonary– Metabolic– Other

• Improving quality of life

AIMS• Discuss primary and secondary prevention of disease• Describe the burden of non-communicable disease and the role of

prevention in health care

• Show that the monitoring and prescription of exercise by doctors can make a major contribution to:– Relieving the burden of health care in South Africa and

elsewhere– Improving the health and quality of life of people– Improving the prognosis of our patients/cardiac patients

PREVENTION OF DISEASE

• Primary prevention– Health promotion

• Secondary prevention– Risk factor modification

• Tertiary prevention– Rehabilitation of disease

BURDEN OF DISEASE

• The double burden of disease– Infectious disease and

famine– Non-communicable

disease

DISEASE BURDEN ATTRIBUTABLE TO 24 GLOBAL RISK FACTORS BY INCOME AND WHO REGION, 2004

The South African scenario

No Risk factor % deaths

No Disease/condition % deaths

1 Unsafe sex/STIs 26.3 1 HIV and AIDS 25.5

2 Hypertension 9.0 2 Ischaemic heart disease 6.6

3 Tobacco smoking 8.5 3 Stroke 6.5

4 Alcohol harm 7.1 4 TB 5.5

5 High BMI 7.0 5 Violence injury 5.3

6 Interpersonal violence 6.7 6 Lower resp infections 4.4

7 High cholesterol 4.6 7 Hypertensive disease 3.2

8 Diabetes 4.3 8 Diarrhoeal disease 3.1

9 Physical inactivity 3.3 9 Road traffic injury 3.1

10 Low fruit/veg intake 3.2 10 Diabetes mellitus 2.6

Norman et al, 2007 in MRC chronic disease report 1995-2005

Modifiable by exercise

No Risk factor % deaths

No Disease/condition % deaths

1 Unsafe sex/STIs 26.3 1 HIV and AIDS 25.5

2 Hypertension 9.0 2 Ischaemic heart disease 6.6

3 Tobacco smoking 8.5 3 Stroke 6.5

4 Alcohol harm 7.1 4 TB 5.5

5 High BMI 7.0 5 Violence injury 5.3

6 Interpersonal violence 6.7 6 Lower resp infections 4.4

7 High cholesterol 4.6 7 Hypertensive disease 3.2

8 Diabetes 4.3 8 Diarrhoeal disease 3.1

9 Physical inactivity 3.3 9 Road traffic injury 3.1

10 Low fruit/veg intake 3.2 10 Diabetes mellitus 2.6

Norman et al, 2007 in MRC disease report 18.9%28.2%

VIDEO CLIP 1

• Question 1:

• Which group of factors that determine a person’s health and longevity can be managed best by medical professionals?

VIDEO CLIP 1

• Question 2:

• What are the current leading causes of death in the world?• In South Africa?

VIDEO CLIP 1

• Question 3:

• What is the current most dangerous non-communicable disease epidemic in the world?

VIDEO CLIP 1

• Question 4:

• What is the most important risk factor for cardiac disease – obesity or inactivity?

VIDEO CLIP 1

• Question 5:

• Name 7 conditions that can be modified effectively by exercise.

EXERCISE IS MEDICINE®

• Dr Robert Sallis, MD

• American College of Sports Medicine (ACSM)

VIDEO CLIP 1

• Question 1:

• Which group of factors that determine a person’s health and longevity can be managed best by medical professionals?

VIDEO CLIP 1

• Question 2:

• What are the current leading causes of death in the world?• In South Africa?

VIDEO CLIP 1

• Question 3:

• What is the current most dangerous non-communicable disease epidemic in the world?

VIDEO CLIP 1

• Question 4:

• What is the most important risk factor for cardiac disease – obesity or inactivity?

VIDEO CLIP 1

• Question 5:

• Is it dangerous for patients to exercise after angioplasty?

VIDEO CLIP 2

• Question 6:

• Name 7 conditions that can be modified effectively by exercise.

VIDEO CLIP 2

• Question 7:

• How much more does it cost to treat inactive patients than active ones in the USA?

VIDEO CLIP 2

• Question 8 :

• Why is a dog really man’s best friend?

VIDEO CLIP 2

• Question 9:

• What are the three most effective interventions to treat coronary artery disease?

RELATIVE RISK FROM PHYSICAL INACTIVITY IS SIMILAR TO THE RISK ASSOCIATED WITH THE 3 OTHER MAJOR RISK FACTORS#

FOR CAD

#Smoking, hypertension, hypercholesterolaemia

CONCLUSION

• Exercise is a powerful tool in the prevention and management of non-communicable disease

• Exercise is more effective in prevention and treatment of many chronic diseases than medication or other modalities

• Exercise should be monitored and prescribed by all doctors

• Table 1: Biological mechanisms by which exercise may contribute to the primary or secondary prevention of CAD12.

• 1. MAINTAIN OR INCREASE MYOCARDIAL OXYGEN SUPPLY• Delay progression of coronary atherosclerosis (possible)

– Improve lipoprotein profile (increase HDL:LDL ratio) (probable)– Improve carbohydrate metabolism (increase insulin efficiency) (probable)– Decrease platelet aggregation and increase fibrinolysis (probable)– Decrease adiposity (usual)

• Increase coronary collateral vascularization (unlikely)• Increase epicardial artery diameter (possible)• Increase coronary blood flow (myocardial perfusion) or distribution (possible)• 2. DECREASE MYOCARDIAL WORK AND OXYGEN DEMAND• Decrease resting heart rate and submaximal exercise heart rate (usual)• Decrease systolic and mean systemic arterial blood pressure during submaximal exercise (usual) and at rest (possible)• Decrease cardiac output at submaximal exercise (probable)• Decrease circulating plasma catecholamine levels (decrease sympathetic tone) at rest (probable) and at submaximal

exercise (usual)• 3. INCREASE MYOCARDIAL FUNCTION• Increase stroke volume at rest and submaximal and maximal exercise (likely)• Increase ejection fraction at rest and during exercise (likely)• Increase intrinsic myocardial contractility (possible)• Increase myocardial function resulting from decreased afterload (probable)• Increase myocardial hypertrophy (probable) #• 4. INCREASE ELECTRICAL STABILITY OF MYOCARDIUM• Decrease regional inchaemia or ischaemia at submaximal exercise (possible)• Decrease catecholamines in myocardium at rest (possible) and atsubmaximal exercise (probable)• Increase ventricular fibrillation threshold attributable to reduction of c-AMP (possible)•  • Note: Expression of likelihood that effect will occur in an individual participating in endurance training program for

16 weeks or longer at 65% to 80% of functional capacity for 25 minutes or longer per session (300kcal) for three or more sessions per week ranges from unlikely, possible, probable, to usual.

•  #: May not reduce CAD risk.

MAIN PHYSIOLOGICAL CARDIAC ADAPTATIONS

• Reduction in heart rate and blood pressure during submaximal exercise

• Increased maximum cardiac output and oxygen consumption (VO2max) during maximal exercise

PERIPHERAL ADAPTATIONS PERSPECTIVE

• Adaptations in CVS function are specific to exercise of trained muscles

• Implication: the major adaptations in CVS function occur in the periphery:– Increased capillarisation– Increased mitochondrial content– Enhanced contractility

EXERCISE CAN BE OF VALUE TO PERSONS WITH IMPAIRED CARDIAC FUNCTION

EXERCISE PRESCRIPTION FOR CHRONIC DISEASE

• Cardiorespiratory fitness• Muscle strength and

endurance• Flexibility

FITT PRINCIPLE

• Frequency• Intensity• Type• Time

• Depending on goal

Primary Prevention: U.S. Physical Activity GuidelinesAge No Chronic Conditions Chronic Conditions

Children & Adolescents (6-17)

60 minutes or more of physical activity every day (moderate*- or vigorous**-intensity aerobic physical activity).

Vigorous-intensity activity at least 3 days per week.

Muscle-strengthening and bone-strengthening activity at least 3 days per week.

Develop a physical activity plan with your health care professional. Avoid inactivity.Refer to the Your Prescription for Health series.

Adults(18-64)

150 minutes a week of moderate-intensity, or 75 minutes a week of vigorous-intensity aerobic physical activityMuscle-strengthening activities that involve all major muscle groups performed on 2 or more days per week.

Develop a physical activity plan with your health care professional. Be as physically active as possible. Avoid inactivityRefer to the Your Prescription for Health series.

Older Adults(65+)

Follow the adult guidelines, or be as physically active as possible. Avoid inactivity.Exercises that maintain or improve balance if at risk of falling.

Develop activity plan with health care professional.Refer to the Your Prescription for Health series.

From the 2008 Physical Activity Guidelines for Americans

For more information on these guidelines, visit www.acsm.org/physicalactivity.

150 minutes per week of moderate-intensity

physical activity• Choose your own schedule • For example: 30 minutes of

moderate-intensity exercise, five days per week OR three 10-minute sessions per day,

five days per week

SECONDARY PREVENTION

• Cardiac exercise rehabilitation programs

• Chronic disease risk reversal programs

EPIDEMIOLOGY

• 1900 – 1960: threefold increase in number of heart disease deaths

• Decrease since 1960s– Better diagnosis and treatment– Awareness– Lifestyle?

EXERCISE AND CAD EPIDEMIOLOGY

Risk of MI in sedentary people 2-3 times that of exercising population

(work or recreation)

Morris 1953, 1973Blair, Kohl, Paffenbarger 1989

0

10

20

30

40

50

60

% of population at

risk

risk factors for CAD

High BP

High cholesterol

Cigarette smoking

Physical inactivity

Primary risk factors for CAD in the USA

RISK IN PRIMARY PREVENTION

• PAR-Q1. Has your doctor ever said that 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?

6. Is your doctor currently prescribing drugs for your blood pressure or a heart condition?

7. Do you know of ANY other reason why you should not do physical activity?

INDIVIDUAL RISK

• History– Risk factors– Medical history– Exercise history– Family history

• Medical examination• Special investigations

EXERCISE TESTING• Field tests

– 6 minutes walk– Unrestricted locomotion test (ULT)– Coopers incremental test

• Laboratory tests– ECG stress testing

• submaximal/maximal– VO2 max– Lactate threshold

END POINTS/INTENSITY

• Dyspnoea scale• Symptoms• Rate of perceived exertion (RPE)• Heart rate

PREDICTING HR MAX

• Nonfat men and women:HR max = 208 – 0.7 X (age, y)

• Body fat > 30%:HR max = 200 – 0.5 X (age, y)

LOWER AND UPPER LIMIT TRAINING HR

• Method 2: Karvonen method (Heart Rate Reserve)– Lower limit target threshold (LLTHR):

• 50% of HRR

– Upper limit target threshold (ULTHR):• 85% of HRR

• LLTHR = [(HRmax – HRrest) X 0.5] + HR rest• ULTHR = [(HRmax – HRrest) X 0.85] + HR rest

EXERCISE PRESCRIPTION

ACSM RECOMMENDATIONS

• Most days of the week, not less than 3• Aerobic exercise• 45 minutes (20 – 60)• Low to moderate intensity

– RPE 13 – 16: “fairly light” – “somewhat hard”– 40 – 80% HRmax

FREQUENCY

• Deconditioned: 2 times per week• Aim for most days of the week, but at

least three

INTENSITY

• For most individuals intensities within range of 45-70% HRR or RPE 11-14 are sufficient to achieve improvements in CR fitness when combined with appropriate frequency and duration of training

• Start low and increase gradually• The higher the intensity, the more benefit

TYPE

• Aerobic exercise– Walking– Jogging– Cycling– Swimming

• Recreational games• Resistance training?

TIME

• 45 – 60 minutes– Warm-up – 10 min– Train at predetermined

intensity – 20-30 min– Recreational games– Cool down– Stretch

PHASES OF PROGRESSION

SECONDARY PREVENTION

• Cardiac exercise rehabilitation programs

• Chronic disease risk reversal programs

WHY?

• Reduces death by re-infarction

• Improves quality of life• Improves functionality• Reduction of many other

risk factors for CAD– HPT– Obesity– Smoking

COMPONENTS OF CHRONIC DISEASE RISK REVERSAL

• Referral• Risk stratification• Exercise testing• Exercise prescription

– Phase 1 – 4

• Monitoring• Dietary assessment and

counseling• Psychological counseling• Risk factor education• Motivational activities,

include family

REFERRAL FOR EXERCISE REHABILITATION

• Why is it not happening?• How should it be done?

– Rehab centres– Biokineticists– Personal trainers– GP guided– Patient guided

RISK STRATIFICATION

• Identify presence of CAD risk factors• Known CVS, pulmonary or metabolic disease• Signs and symptoms of CVS, pulmonary of

metabolic disease

ACSM CAD RISK FACTOR THRESHOLD

1. Family history of MI, revascularization, sudden death < 55 in male relative or <65 in female relative

2. Cigarette smoking, current or previous 6 months3. Hypertension >140/90mmHg or on medication4. Dislipidaemia:LDL>3.4mmol/l, HDL<1.03mmol/l, total chol >5.2mmol/l, or on

medication5. Impaired fasting glucose >5.6mmol/l6. Obesity: BMI >30kg/m2 ; waist >102cm or 88cm; waist to hip ratio >0.95 and

0.867. Sedentary lifestyle

ACSM CAD RISK FACTOR THRESHOLD

1. Family history of MI, revascularization, sudden death < 55 in male relative or <65 in female relative

2. Cigarette smoking, current or previous 6 months3. Hypertension >140/90mmHg or on medication4. Dislipidaemia:LDL>3.4mmol/l, HDL<1.03mmol/l, total chol >5.2mmol/l, or on

medication5. Impaired fasting glucose >5.6mmol/l6. Obesity: BMI >30kg/m2 ; waist >102cm or 88cm; waist to hip ratio >0.95 and

0.867. Sedentary lifestyle

ACSM RISK FACTOR CATEGORIES

• Low risk– Men <45, women <55, asymptomatic, no more than one

risk factor• Moderate risk

– Men >45, women >55, OR two or more risk factors• High risk

– 2 or more signs and symptoms, or known disease

Low risk pts – No complicated factors by day 4

-LVEF > 50%

-No significant ventricular ectopy

Moderate risk pts – Poor ventricular function –LVEF 35-50%

- Severe myocardial ischemia at low levels of activity after day 4

-ST depression <2mm flat or downsloping

High risk pts – Sustained myocardial ischemia

- Left ventricular failure, LVEF <35%

- Hypotensive response

- Severe dysrhythmias

Post-Myocardial Infarction risk stratification

CONTRA-INDICATIONS

• Unstable angina• BP 200/100mmHg• Aortic stenosis• Acute pericarditis• Debilitating non-cardiac disease• Drop of 20mmHg in resting BP• Uncontrolled atrial tachycardia• Recent pulmonary embolism• 3rd degree heart block• Thrombophlebitis• Resting ST segment displacement (>3mm)• Uncontrolled DM• Orthopedic limitations to exercise

MEDICATION AND EXERCISE

• Beta blockers• Calcium channel antagonists• Nitrates

PULMONARY REHABILITATION

• Optimize respiratory system medication and technique• Correction of hypoxaemia• Desensitization to dyspnoea, fear and other limiting

factors• Breathing retraining• Energy conservation

– Balance, coordination, mechanical efficiency, ergonomics

• Exercise training to improve physical deconditioning

PULMONARY REHABILITATION

• Exercise training to improve physical deconditioning– Oxygen administration when PO2 < 55mmHG or O2 saturation<

88%– Aim for saturation >90%

• 20 – 30 minutes duration, according to ability• Interval exercise – 3 sessions of 10 minutes• Group interaction

TAKE HOME MESSAGE

• Exercise reduce risk of chronic disease in the community• Chronic disease can and should be treated with exercise

and other rehabilitation modalities

MORE QUESTIONS

• What is the exercise prescription for primary prevention of coronary artery disease?

MORE QUESTIONS

• What is the exercise prescription for secondary prevention of coronary artery disease?

What if there was one prescription

that could prevent and treat

dozens of diseases, such as diabetes,

hypertension and obesity?

Would you prescribe it to your patients?

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

DISCUSSION

REFERENCES

• www.exerciseismedicine.org

• www.acsm.org/physicalactivity

• Jonas S, Phillips EM, 2009. ACSM’s Exercise is Medicine – A Clinician’s Guide to Exercise Prescription. Philadelphia, Lippincott-Williams

THANK YOU!

Dr Louis Holtzhausen

Division Sport and Exercise Medicine

HoltzhausenLJ@ufs.ac.za