Exercise is MedicineAre you getting the right dose?

Exercise is Medicine

“If we had a pill that contained all the benefits of exercise, it would be the most widely prescribed drug in the world”….. Ronald M. Davis, M.D. President AMA

Coronary Heart Disease•Affects > 82,000 Americans

•1 in 3 adults have 1 or more CHD risk factors

•1 person dies every 39 seconds from CHD

•CHD kills more women than the next 14 causes of death combined

•Estimated 250,000 premature deaths in U.S. annually directly attributable to physical inactivity

•Source: AHA update 2012

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

Cooper Clinic Study 201241,000 men monitored for average of 17 yrs

Study found high degrees of fitness substantially reduced risk of death from CHD regardless of LDL level

Conclusion included persons with LDL of <100 and poor fitness had higher risk for death than LDL > 190 and high level of aerobic fitness

Exercise ResearchDirect relation between inactivity and cardiovascular

mortality. Inactivity is an independent risk factor for of CAD.

Exercise capacity is a more powerful predictor of mortality among men than other established risk factors for CAD.

Physical fitness has been clearly associated with improvements in lipid profiles.

Hypertension (AHA) 2005Studied cardiovascular effects of aerobic exercise in

resistant hypertension

Resistant hypertension defined as BP >140/90 mmHg despite use of 3 antihypertensive agents

Findings..exercise significantly SBP&DBP ambulatory BP by 6+12 & 3+ 7 mmHg respectively

Conclusions: low responsiveness to drug therapy doesn’t equate to low responsiveness to non-pharmacological approach..i.e. EXERCISE

• Tremendous health benefits are seen with even low levels of exercise.• Amount of exercise needed to benefit health is much lower than amount

needed for fitness.

Regular physical activity at the correct intensity:• Reduces the risk of heart disease by 40%.• Lowers the risk of stroke by 27%.• Reduces the incidence of diabetes by almost 50%.• Reduces the incidence of high blood pressure by almost 50%.• Can reduce mortality and the risk of recurrent breast cancer by almost

50%.• Can lower the risk of colon cancer by over 60%.• Can reduce the risk of developing of Alzheimer’s disease by one-third.• Can decrease depression as effectively as Prozac or behavioral therapy.

Exercise As Medicine

Decision Time

When Doctors Prescribe ExerciseSpanish study in Archives of Internal Medicine looked at

4000 patients half given general advice on exercise, the other half given an actual prescription to do so. In 6 mo. Ex Rx group was significantly more active

65% of patients surveyed would be more interested in exercising if prescribed by their MD

41% of physicians talk to their patients about exercise but don’t offer suggestions as to best ways to be physically active

Power of the PadClear distinction between doctor’s advice & doctor’s

orders

Basis of “Exercise is Medicine” campaign

Exercise truly is a form of treatment

Choosing specific goals vs “get some exercise”

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

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What is Cardiac Rehabilitation?Medically supervised

Lifestyle modification

Monitored progressive exercise/activity

Inpatient-Outpatient-Lifetime

Individualized, typically 3x/week, up to 12 weeks

Physician Referral Required

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Goals of Cardiac Rehab

Identify, modify, and manage risk factors to reduce disability/morbidity & mortality

Improve functional capacity

Alleviate/lessen activity related symptoms

Educate patients about the management of heart disease

Improve quality of life

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Lifestyle Benefits:Risk Factor and Lifestyle ModificationSmoking cessationLipid improvementBlood pressure controlExercise guidanceWeight managementDiabetes controlStress management

Circulation 2013 Study of 846 patients that underwent CABG

Looked at survival after 10 yrs post-op, CR yes or no

At end of 10 yrs had 45% in mortality for CR attendees vs non-attendees

Circulation 2012Studied CR attendance & outcomes for CAD patients

>5800 patients, compared completion vs non completion of CR over a 14 yr period

Findings: CR completion was associated with risk of mortality & frequency of all cause & cardiac specific hospitalizations.

Components of ExRx for Risk Factor Reduction

Aerobic exerciseStrength training

F.I.T.T. PrincipleFrequency

3-5 x/week

IntensityHR 50-75% of HRR, 60-80% of VO2Max

Conversation Pace

RPE

RHR + 20

Time15-60 min/session

Type

Stages of ConditioningInitial Phase

Duration: 4-6 weeks

Goal: to increase frequency, proper form, & develop “good habits”

Improvement PhaseDuration: 4-6 mos.

Goal: to gradually increase intensity & duration

Maintenance PhaseDuration: after 6 mos

Goal: maintain CV fitness, avoid overuse injuries

Strength TrainingPositive impact on;

Muscle mass & strength

Bone density

Metabolism

Balance

Strength TrainingSignificant correlation between muscle strength and;

Independence

Performance of ADL

Preferred walking speed

Strength TrainingStart with resistive bands, light weights, cans of food

Chair exercises

10-15 reps of 5-7 exercises 2-3x/week

Lift 2 sec, lower 4 sec

Focus on large muscle groups

Precautions

• Evidence is now overwhelming on the health burden of physical inactivity.

• The benefits of exercise in the treatment and prevention of chronic disease cannot be denied.

• We cannot continue to ignore this evidence when formulating treatment plans for our patients.

• No patient should leave a doctor’s office without an assessment of his/her physical activity and proper prescription of an exercise program, or a referral to a certified fitness professional.

Summary

Mercy’s SolutionMercy Health Fitness Program…only certified program in

area by Medical Fitness Assoc (MFA)

Cardiac Rehab Program certified by AACVPR

Medical approach to fitness/wellness programming

Staff all degreed in exercise science

Easy referral process