Physical Activity for the Sedentary,

An Oxymoron?

Disclosure

• Conflicts (Inner): Frequently Conflicted between the Universities where my daughters and I went to

school for Donations. University of Arizona

Universities of California, Berkeley and Los Angeles

Linguist Interview

• The question put to him by audience was this:

• "Some say there is no difference between 'complete' and 'finished.'

• Please explain the difference in a way that is easy to understand."

3

Linguist Response

• When you marry the right woman, you are 'complete.'

• If you marry the wrong woman, you are 'finished.'

• And, if the right one catches you with the wrong one, you are

• 'completely finished.’”

• Are we ever Finished in our Medical Treatment?

4

Presentation Objectives

1)Why are we Sedentary ?

2) Describe The Right Physical Activity Diagnosis and Treatments Strategies that Works in a Clinical Setting for the Sedentary.

Physical activity is all movements in everyday life, work, recreation, exercise, and sporting activities...”

World Health Organisation, 1997

‘Activities that involve movement of all the major muscle groups and the body (trunk) from one place to another.’

Start Active, Stay Active, 2011

Definitions of Physical Activity

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All PHYSICAL Activities Count

Physical Activity: What Matters?

Tremblay et al. (2010) Appl Physiol Nutr Metab

Sleep Sedentary Light

intensity

Moderate

intensity

Vigorous

intensity

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Our Patient Sample

How Do We Compare With Other Countries For Not Being Physically Active?

Everybody Active, Every Day (2014); Public Health England,

based on Hallal et al. (2012) Lancet

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International comparison of physical inactivity (at ages 15 and over)

Proportion Who Are Not Active Note: Comparator = Not meeting any of the following per week: (a) 5 x 30 mins moderate-intensity activity; (b) 3 x

20 mins vigorous-intensity activity; (c) equivalent combination achieving 600 metabolic equivalent-min.

How Does Inactivity Compare With The Top 5 Non-Communicable Disease Risks For Mortality?

WHO (2009) Global health risks: mortality and burden of disease

attributable to selected major risks

Physical Activity: Who Gains The Most?

“More is better. Some is much better than none.”

Moore et al. (2012) PLOS Medicine

Mortality after age 40 Years gained after age 40

Biggest drop

in mortality

Biggest gain

in years

We Do Less Activity As We Age.

WHY?

A

Biggest drop

Prevention of Chronic disease REVIEW

Physical activity reduces risk of

• Cardiovascular disease • Coronary heart disease • Stroke

• Musculo-skeletal • Osteoporosis • Back pain

• Mental health • Depression • Mental function

• Cancer • Colonic cancer • Breast cancer • Lung cancer • Endometrial cancer

• Metabolic disease • Obesity • Non-alcoholic fatty liver disease • Type 2 diabetes

Physical Activity Reduces Risk Of The Following Conditions By At Least 20%

Physical Activity contribution to reduction in risk of mortality and long term conditions

Disease Risk reduction Strength of evidence

Death 20-35% Strong

CHD and Stroke 20-35% Strong

Type 2 Diabetes 35-40% Strong

Colon Cancer 30-50% Strong

Breast Cancer 20% Strong

Hip Fracture 36-68% Moderate

Depression 20-30% Strong

Hypertension 33% Strong

Alzheimer’s Disease 20-30% Moderate

Functional limitation, elderly 30% Strong

Prevention of falls 30% Strong

Osteoarthritis disability 22-80% Moderate

Start Active, Stay Active (2011) based on US Department of Health and Human Services Physical Activity Guidelines Advisory Committee Report (2008)

How is Physical Activity Protective?

Systemic Inflammation

Visceral Fat Muscle

Anti-inflammatory

Myokines

Physical Activity

Chronic low-grade systemic inflammation thought to be

the root cause of morbidity from inactivity

Clinical Tips

• Consider mentioning physical activity in all consultations (at least as often as smoking)

• Retirement does not mean ‘take it easy’: stay active to maintain strength, cognitive function, and independence

• Physical activity is effective as both prevention and treatment for numerous conditions, including cancer

• ‘Moderate’ activity differs by individual (it may be light walking for previously sedentary adults) – explore how to make it achievable

Give

Permission

To Be Active!

There Are Dangers of Exercise

• Sudden death is rare:- • under 35yrs - HOCM (genetic), • over 35yrs - coronary artery

disease most common. Pre-exercise screening in Italy is routine and deaths reduced.

• Environmental: traffic, clothing, hyper/hypothermia, sun damage, hyponatraemia

• Psychological: after injury & addiction

• Eating disorders and ‘female athlete triad’

• Immunosuppression – prolonged exercise can suppress immune system

Practitioners Own Participation Provides a Role Model and Carries an Important Message

• Physical activity levels have decreased as advances in technology increases, Thus our lives are more sedentary

• Medical schools should promote medical student physical activity habits to increase the rates and quality of future exercise counselling delivered by doctors.

• Why it does not?

Medical Staff Feedback Findings

• ‘I felt it was the natural conclusion to give them something ( Recommendation)

• ‘I took the aim of the exercise, not as trying to get a therapeutic level of exercise yet but to get something started’

• ‘Without an actual goal they don't know if they are doing what they agreed to do’

• ‘It encouraged me to talk to them about appropriate exercise for them rather than giving them guidelines’

Walk with Our Docs to Get Healthy

Recommending Exercise – 5 As Headings

1.Assess

2.Advise

3.Agree

4.Assist

5.Arrange follow up and re assess

Recommend/Not Prescribe Data Not Known

1. ASSESS - physical activity levels. Is there a need to change?

• what do they like doing?

• beliefs and knowledge

• opportunities

2. ADVISE - amount required e.g. 5x30 mins to reach heart rate > 120bpm

• health risks from remaining inactive

• benefits of change

• exercise benefit on BP, blood glucose

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As they walk in from Hallway Greet Patient. Hand Shake: Measure of Grip Strength Watch them walk to your Consult Room looking for: Balance, Walking Gait, Posture

Patient Assessment

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Ask Patient to walk about 5-7 yards. Look at walking gait for: Stride length, Skeletal system: Head (TILT), Shoulder symmetrical hip ,knee and ankles for Linearity and Flexibility.

Patient Assessment: 4 Factors

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Balance in walk is included because of drug and Skeletal regression. Balance Affects ankle flexibility, Balance, and stride length (Shuffle feet) . Feet pronation (Inward) OR Feet Supination (Outward) Examine heels of patient shoes for pronation and supination

Patient Assessment

Assessment In Primary Care

• Use physical activity questionnaire (PARQ) to assess and generate discussion

• Quality and outcomes framework (QOF) – physical activity is part of CV risk assessment.

Recommendations

3. AGREE - action plan • Realistic goals based on Physical Activity they feel they can do and would enjoy

• Ways to measure progress, e.g. fitness, stamina, engagement, enjoyment

4. ASSIST – identify barriers and explore solutions • Identify community opportunities for PHYSICAL ACTIVITY

• Health walks (local or practice based)

• Signpost/refer to support e.g. health trainers

Recommendations -

ARRANGE follow up and assess again

• Identify barriers and relapse risks

• Double-check the patient’s goals

• Provide encouragement

Chronic conditions require long-term input and support. We don’t prescribe an antihypertensive and then ignore patients outcome.

Elderly

• Chronic disease has a major impact on quality of life of the elderly.

• Cardiovascular and muscle strength exercises have a positive effect on prevention of falls, mobility & independent living.

• Weight bearing (e.g. walking) and non weight bearing exercise (e.g. swimming) all beneficial.

• Group Physical Activity improve loneliness, anxiety, depression and slows cognitive decline.

Guidelines on Physical Activity for Adults and 0lder Adults

• 150 mins of moderate intensity activity in bouts of at least 10 minutes/week

Or 75 minutes of vigorous intensity activity

Or a combination of both

• Muscle-strengthening at least 2 days

• Limit time sitting for extended periods

• For older adults (65+) - Balance and co-ordination activities at least 2 days/week

“More is better. Some is better than none.”

Physical Exercise Recommendations

• Aerobic At least 3 days/wk, 5 recommended 40-60% of maximal aerobic capacity

– ACSM/AHA: at least 150 min/wk (30 min/5 days)

• Intense: at least 60 min/wk (20 min/3 days)

– Any physical exercise using large muscle groups and sustaining an increased HR is beneficial.

Physical Exercise Recommendations

• Resistance • At least 2 days/wk, nonconsecutive

Ideally: 3 days/wk

• Moderate intensity (50% of 1RM)

• 5-10 exercises using major muscle groups

• Perform 10-15 reps near to fatigue per set

• Progression should occur slowly

• Supervision is recommended

Acute Effects of PA

• More reliance on carbohydrates with increasing exercise intensity

• Aerobic training

– Improves blood glucose and insulin action acutely

• Resistance training

– Results have not been reported

• Increased glucose uptake into muscles

Physical Activity Needs

to be Treated as a Drug.

Why?

Comparison Between Exercise Therapy and Drug Therapy Parameter Exercise Drugs

Type Aerobic, anaerobic, stretch, relaxation, flexibility, coordination, toning

Antibiotics, analgesics, anti-inflammatories, sedatives, antidepressants, hormones

Frequency 1-3 times/day, 7 days/week

1-3 times/day, 7 days/week

Duration Lifetime Short-term or lifetime

Time of day Various Various

Contraindications Illness, pain Allergy, rash, polypharmacy, other diseases

Side effects Overuse injuries to muscles, tendons, or ligaments; joint injury; fatigue

Organ damage, anemia, gastrointestinal symptoms, drowsiness, etc.

Patient education Required Required

Compliance Variable Variable

Ethical discussion:-

• Does lack of Physical Activity opportunity equate to child neglect or elder abuse??

• YOUR THOUGHTS FOR PANEL DISCUSSION?

Summary

• Physical Activity is medicine’ and beneficial for all ages

• More is better. Some is much better than none.

• Taking time to counsel and encourage patients improves health, happiness and independence,

• and decreases the financial burden on patient, family and Government.

Sedentary Behaviour

•A state of muscle inactivity associated with metabolic risk factors, cardiovascular disease, and mortality regardless of engagement in moderate-to-vigorous activity

•No standard recommendation (yet) for ‘ideal sitting time’ •Breaking-up sitting every 20 minutes with just 2 minutes of light or moderate walking can improve postprandial glucose and insulin responses to food

•Key is to avoid prolonged periods of sitting – move often • Get UP Up Every 2 Hours and Stretch

Hamilton et al. 2007, Diabetes; Healy et al. 2011, Eur Heart J; Koster

et al. 2012, Plos One; Dunstan et al. 2012; Diab Care

“All parts of the body which have a function, used in moderation and

exercised in labours in which each is accustomed, become thereby healthy,

well-developed and age more slowly, but if unused and left idle, they become liable to

disease, defective in growth and age quickly.”

- Hippocrates