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Every Patient is an Athlete:

Using Exercise as Medicine

Carlin Senter, M.D. Primary Care Sports Medicine

UCSF Medicine and Orthopaedics February 10, 2015

Outline

1. Why every person should be an athlete

2. The prescription for physical activity

3. Motivation

Case

• 55 y/o woman presents for routine annual exam. No complaints but she is shocked that she gained 10# since she saw me last year. Takes no medications.

• BP 140/80, HR 80, Height: 5’3”, weight 170# (BMI 30)

• Labs:

– Fasting blood glucose 104

– Total cholesterol 192, Triglycerides 110, HDL 50, LDL 118

Definitions

• Physical activity: any body movement that results in energy expenditure (exercise, gardening, biking to work)

• Exercise: physical activity that is planned, structured, repetitive with objective to improve or maintain physical fitness.

ACSM Position Stand on Prescribing Exercise, Med Sci Sports Ex, 2011.

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Physical inactivity in the US, 2008

http://apps.nccd.cdc.gov/DDT_STRS2/NationalDiabetesPrevalenceEstimates.asp

x?mode=PHY. Accessed Nov 13, 2011.

What % of adults in California did no leisure-time physical activity in 2008?

A. 5%

B. 10%

C. 15%

D. 20%

E. 25%

http://apps.nccd.cdc.gov/PASurveillance/StateSumResultV.asp

Women less active than men

Percent of no leisure time physical activity in the United States

– Women: 26.2%

– Men: 21.7%

Centers for Disease Control and Prevention. US Physical Activity Statistics 2007. Accessed November 2012.

Why every person should be an athlete

• Numerous health benefits

–Strong evidence

–Moderate evidence

Strong evidence that physical activity associated with lower risk of

• Heart disease

• Stroke

• High blood pressure

• High cholesterol

• Type 2 diabetes

• Colon cancer

• Breast cancer

• Falls

US Dept Health and Human Services. Physical Activity Guidelines Advisory

Committee Report, 2008:

http://www.health.gov/paguidelines/guidelines/chapter2.aspx. Accessed 11/6/2011.

What is heart disease?

Cardiovascular disease 1. Heart attack (blood flow to heart blocked) 2. Stroke (blood flow to brain blocked)

http://watchlearnlive.heart.org/CVML_Player.php?moduleSelect=hrtatk

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http://www.cdc.gov/dhdsp/data_statistics/fact_sheets/images/fs_women_heart_large.jpg

Heart Disease #1 Killer of Women in US

• 1 in 4 women dies from heart disease

• Approximately the same number of women and men die from heart disease each year

• Only 54% of women recognize that heart disease is their #1 killer

• 2 of every 3 women who die of heart disease have no warning symptoms

http://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_women_heart.htm

Heart disease risk factors

• Physical inactivity

• Obesity

• Family history

• Age

• Male gender

• Smoking

• High cholesterol

• High blood pressure

• Diabetes

http://www.heart.org/HEARTORG/Conditions/HeartAttack/UnderstandYourRisk

ofHeartAttack/Understand-Your-Risk-of-Heart-Attack_UCM_002040_Article.jsp

www.heart.org/gglRisk/main_en_US.html

Physical Activity Lowers Heart Disease Risk in Women

• Women’s Health Initiative Observational Study

– Prospective

– 74,000 postmenopausal women

– Ages 50-79, diverse racial and ethnic backgrounds

– Walked briskly or exercised vigorously at least 2.5 hours/week

– 30% lower risk of heart attack and heart failure

Manson JE et al. Walking compared with vigorous exercise for the prevention of cardiovascular events in women. N Engl J Med. 2002.

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Physical activity lowers heart disease risk in dose-dependent fashion

• Compared to people with no physical activity

– 150 min/week of moderate-intensity physical activity 14% lower risk heart disease

– 300 min/week 20% lower risk

Sattelmair J et al. Circulation, 2011.

What is Type 2 Diabetes?

http://pixshark.com/type-2-diabetes-pictures.htm

Women with Diabetes

• 1/11 people in US has diabetes

• 50% of these are women

• Women with diabetes have shorter life expectancy than women without diabetes

• Greater risk blindness than men with DM

• Increased health risk during pregnancy (eye problems, kidney problems, higher blood sugar levels)

http://www.cdc.gov/diabetes/risk/gender/women.html

Exercise as Medicine: Diabetes Prevention

• Randomized controlled trial • 3 groups: placebo, metformin, lifestyle groups • Lifestyle: diet and 150min exercise/week with goal weight

loss of 7% • Average age 51 yrs, average f/u 2.8 years • Incidence of diabetes

– Placebo: 11/100 person-years – Metformin: 7.8/100person-years – Lifestyle 4.8/100 person-years

Exercise as Medicine: immediate benefits CVD, Diabetes

• Blood pressure o Exercise session 50-100% of maximum

intensity ↓ Systolic blood pressure 18-20mmHg ↓ Diastolic blood pressure 7-9mmHg lasting 12-16 hours after exercise

• Blood sugar o Exercise at 55-75% of maximum intensity

↓ blood sugar 20-40 mg/dL lasting 2-3 days

Kesaniemi et al, Medicine & Science in Sports & Exercise, 2001

Breast cancer

• Cancer: cells growing out of control • Breast cancer: when the out-of-control cells are in the

breast • After skin cancer, the most common cancer affecting

US women • The most common cause of death from cancer in

Hispanic women in the US • The 2nd most common cause of death from cancer in

non-Hispanic US women

http://www.cdc.gov/cancer/breast/basic_info/index.htm http://www.cdc.gov/cancer/breast/statistics/index.htm

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Physical Activity Lowers Risk of Breast Cancer

• Lowers risk – Breast cancer – Breast cancer recurrence – Death from breast cancer

• Mechanisms – Leaner body weight lower risk – Possibly lower estrogen levels lower risk – Possibly boost in immunity lower risk

http://ww5.komen.org/BreastCancer/LackofExercise.html

Moderate evidence that physical activity associated with

Lower risk of…

• Depression

• Hip fracture

• Lung cancer

• Endometrial cancer

Improved…

• Bone density

• Sleep quality

• Weight maintenance after weight loss

• Cognitive ability

US Dept Health and Human Services. Physical Activity Guidelines Advisory

Committee Report, 2008:

http://www.health.gov/paguidelines/guidelines/chapter2.aspx. Accessed 11/6/2011.

Bone density

• Bone density peaks around onset of adulthood

• Bone density declines after menopause

• Osteopenia

• Osteoporosis

Slide courtesy of Marci Goolsby MD.

Physical activity effects on bone density

• Cochrane - Overall small effect but statistically significant improvement in bone density – Progressive resistance strength training for legs increases

bone density of hip – Combination exercise programs increase bone density of

spine

• Expert consensus – may not increase bone density but slow the rate of loss

Physical activity lowers fall risk • Benefits for fall

prevention:

– Weight control

– Balance

– Strength

– Mobility

– Reaction time

– Improved bone, muscle, joint health

WHO Global Report on Falls Prevention in Older Age, 2007.

Slide courtesy of Marci Goolsby MD.

http://www.timesofmalta.com/articles/view/20110529/health-fitness/Tai-chi-improves-balance-mental-health-in-elderly-study.368032

Physical activity lowers risk of fracture

• Back strengthening program decreased vertebral fractures in 50 postmenopausal women (Sinaki, 2002)

• Nurses’ Health Study: Risk of hip fracture was reduced by 55% in those who did about 6 hours brisk walking/week compared to sedentary (Feskanich, 2002)

Slide courtesy of Marci Goolsby MD.

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What’s better: daily exercise or avoiding a sedentary lifestyle?

Medicine & Science in Sports and Exercise, 2009.

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Benefits of walking at lunch

• Group of 56 physically inactive employees – Avg age 48, 93% female

• Randomized – Walking: 30 min 3x/week x

10 weeks – No walking group

• Walking group demonstrated more enthusiasm, relaxation and less nervousness at work

Thøgersen-Ntoumani C et al. Changes in work affect in response to lunchtime walking in previously physically inactive employees: A randomized trial. Scand J Med Sci Sports. 2015 Jan 6.

What matters more: Fitness or Fatness?

http://well.blogs.nytimes.com/2012/03/07/getting-fat-but-staying-fit/?scp=5&sq=exercise&st=cse

J Am Coll Cardiol. 2012 Feb 14;59(7):665-72.

The exercise prescription: What’s the right dose of activity?

Credit: Piotr Redlinski for The New York Times

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Physical activity recommendations: 4 types of activities

Balance

Strength Flexibility

CV fitness

Physical activity recommendations: components of each activity

•Frequency

• Intensity

•Time

•Type

Estimating exercise intensity

Low Moderate Vigorous

HR <50% max 50-70% max >70% max

Talk test Can talk and sing Can talk but not sing

Can only say a few words before pause for breath

Borg rating of perceived exertion

9 – very light (slow walk 11 – light

13 – somewhat hard 15 – hard (very heavy, tired)

17- very hard 19 – extremely hard 20 - max

Exercise prescription: Combine activity with components

•Frequency

• Intensity

•Time

•Type

Balance

Strength Flexibility

CV fitness

CV fitness recommendations adults ages 18 and older

Frequency Intensity Time Type

5x/week Moderate 30 minutes Major muscle groups

OR

Frequency Intensity Time Type

3x/week Vigorous 25 minutes Major muscle groups

http://www.cdc.gov/physicalactivity/everyone/guidelines/adults.html

Accessed February 9, 2015.

Balance recommendations

ACSM Position Stand on Prescribing Exercise, Med Sci Sports Ex, 2011.

Frequency Intensity Time Type

2-3d/week Unknown 20 minutes Tai Chi, tennis, yoga, surfing

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Strength recommendations

ACSM Position Stand on Prescribing Exercise, Med Sci Sports Ex, 2011.

Frequency Intensity Time Type

2-3d/week Novice: 40-50% Experienced: 80%

Unknown All major muscle groups

Flexibility recommendations

ACSM Position Stand on Prescribing Exercise, Med Sci Sports Ex, 2011.

Frequency Intensity Time Type

2-3d/week Stretch to feeling of tightness

Hold 10-30 seconds All major muscle-tendon units

Case

• 55 y/o woman presents for routine annual exam. No complaints but shocked that she gained 10# since she saw you last year. Takes no medications.

• BP 140/80, HR 80, Height: 5’3”, weight 170# (BMI 30)

• Labs:

– Fasting glucose 104

– Total cholesterol 192, TG 110, HDL 50, LDL 118

What treatment would most benefit this patient now and in the long run?

Case: Exercise Rx

• F: 3x/week

• I: moderate

• T: 15 minutes

• T: brisk walking

http://www.homegymmachinesguide.com/images/The%20Benefits%20Of%20Walking%20Image.jpg

Motivation

http://i.telegraph.co.uk/multimedia/archive/02776/fitbit_2776467b.jpg

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What makes a successful exercise program?

• Program characteristics

– Moderate intensity

– Supervised activity by experienced leader

– Group support

– Pedometers

• Individually tailored program

– Goal-setting

– Reinforcement: social support for behavioral change

– Problem-solving

http://en.wikipedia.org/wiki/File:07-06_WtrAerob1a.jpg

Should I Wear a Fitbit?

• What do they track? – Steps – Sleep – Inactivity (with alert) – Food, water, caffeine intake – Heart rate – Connect with smart phone apps

Can activity trackers change behavior?

• Fitbit, Jawbone, Nike products use behavioral change techniques associated with increased physical activity – Goal setting – Problem solving – Self-monitoring – Feedback on behavior – Prompts/cues – Rewards

Lyons EJ1, Lewis ZH, Mayrsohn BG, Rowland JL. Behavior change techniques implemented in electronic lifestyle activity monitors: a systematic content analysis. J Med Internet Res. 2014 Aug 15;16(8):e192.

Limitations of activity trackers using only an accelerometer

• Best for walking, running • Not good for exercise that is more stationary

– Yoga – Weight lifting or strength work – Cycling (though other measures can be used)

• Can be improved if using heart rate data as well • Most useful for general day to day activity

measurement compared to days prior – Weekends to weekdays

Do activity trackers improve health?

http://www.cdc.gov/physicalactivity/everyone/guidelines/adults.html

Accessed February 9, 2015.

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http://go4life.niapublications.org/ Accessed October 23, 2011.

http://go4life.niapublications.org/try-these-

exercises#strength-exercises Accessed October 23, 2011.

Physical activity apps Feeling ready for action?

First check with your doctor

• Discuss

– Heart problems

– Arthritis

– Joint replacement history

– Diabetes

– Osteoporosis

• May recommend pre-exercise testing or exercise modifications

Come visit us! UCSF Sports Medicine UCSF Orthopaedic Institute at Mission Bay

Appointments

415-353-2808

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“All parts of the body if used in moderation and exercised in labors to which each is

accustomed, become thereby healthy and well developed, and age slowly; but if

unused and left idle, they become liable to disease, defective in growth, and age

quickly.” Hippocrates

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Carlin Senter, M.D. Primary Care Sports Medicine

UCSF Medicine and Orthopaedics

Thank you • CV fitness: 150 minutes/week • Strength*

– Major muscle groups – 8-12 repetitions – Intensity of 5-8 on a scale of 0-10 – *Modify if fracture history

• Balance – Daily x 15-20 minutes – Tandem walk, walking heels or toes, Tai Chi

Osteoporosis exercise Rx: fall prevention and bone density

maintenance

Giangregorio LM et al. Too Fit To Fracture: outcomes of a Delphi consensus process on physical activity and exercise recommendations for adults with osteoporosis with or without vertebral fractures. Osteoporosis Int (2014).

Osteoporosis exercise Rx: Fall prevention

Giangregorio LM et al. Too Fit To Fracture: outcomes of a Delphi consensus process on physical activity and exercise recommendations for adults with osteoporosis with or without vertebral fractures. Osteoporosis Int (2014).

• Particularly important for those with history of spine fracture

• Turn the body by stepping rather than twisting the body

• Knee bend and hip hinge to minimize spine loading during bending.

Osteoporosis exercise Rx: Safe movement

Giangregorio LM et al. Too Fit To Fracture: outcomes of a Delphi consensus process on physical activity and exercise recommendations for adults with osteoporosis with or without vertebral fractures. Osteoporosis Int (2014).