Is Physical Fitness the New Fountain of Youth · 2017-04-07 · Lucas Cranach the Elder, 1546 :...

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Aging & Exercise Is Physical Fitness the New Fountain of Youth Marc Kowalsky, MD March 8, 2017

Transcript of Is Physical Fitness the New Fountain of Youth · 2017-04-07 · Lucas Cranach the Elder, 1546 :...

Page 1: Is Physical Fitness the New Fountain of Youth · 2017-04-07 · Lucas Cranach the Elder, 1546 : All-Cause Mortality • Age > 60 years – Risk for all-cause mortality decreases by

Aging & Exercise Is Physical Fitness the New Fountain of Youth

Marc Kowalsky, MD March 8, 2017

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“To keep the heart unwrinkled, to be hopeful, kindly, cheerful, reverent – that is to triumph over old age”

Thomas Bailey Aldrich

poet, critic, former editor of The Atlantic

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The Aging Misconception

• “a disproportionate amount of healthcare services are used by older people …”

• characterizes older people as societal and economic burden

Advanced age must be synonomous with poor health

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The Aging Misconception

• Aging Well – The ability to lead a healthy, socially inclusive

lifestyle relatively free from illness or disability – Being physically active, with a structured exercise

program, and following good nutrition practice • Health Span ≠ Life Span

Older people remain capable of making significant social, economic and cultural

contributions to society. Witard et al. 2016

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The Problem

• Physical inactivity, NOT aging, is the burden

• Approximately 3.2 million deaths each year are attributable to physical inactivity

• Physical activity can reduce national healthcare costs by $76 billion

Pratt et al. 2000

World Health Organization. 2013

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Lifestyle choices

• Alcohol

• Smoking

• Diet

• Physical Activity

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The Impact of Diet

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The Impact of Physical Fitness

“If you had to pick one thing, one single

thing that came close to the fountain of

youth, then it would have to be exercise.”

James Fries, MD

Professor Emeritus of Medicine Stanford University

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Exercise Science

• Hippocrates & Galen

• Krogh & Hill (1920, 1922) – Nobel Prize

• Morris (1953) – London conductors

• Paffenbarger & Hale (1975) – Longshoremen

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The Impact of Physical Fitness

Presenter
Presentation Notes
Explosion of interest in physical fitness Exponential rise in scientific publications addressing health and fitness
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Epidemiology

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Epidemiology

• Over-85 age group fastest growing segment of US population

• < 40% of older Americans meet established guidelines for physical activity.

• > 60% of Americans older than 75 years report no recreational physical activity

Presenter
Presentation Notes
30 minutes per day, > 5 days / week MIPA 20 minutes per day, > 3 days / week VIPA
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Disability Pathway

Pathology Impairment Functional Limitation

Disability

Presenter
Presentation Notes
Pathology: type II muscle fiber atrophy Impairment: loss of muscle strength Functional Limitation: loss of mobility Disability: limitation in performing socially defined roles/activities within one’s environment
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Age-related changes

• Sarcopenia

• Decline in aerobic capacity

• Decline in energy expenditure

• Mobility difficulty and disability

• Chronic medical conditions

Presenter
Presentation Notes
Aerobic capacity decrease is due to decreased cardiac output, loss of muscle oxidative capacity, and decreased mitochondria After age 70, 10% per year will develop mobility difficulty, and 1/3 of these will have severe mobility disability Incidence of these chronic diseases more than doubles in the 10 years that follow retirement. Of people aged over 75 years, 30 % report chronic musculoskeletal conditions; 32 % report heart and circulatory conditions and 13 % report endocrine or metabolic conditions
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Aging Trajectory

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Definitions

• Performance-related Fitness: Training programs with objective to improve performance among competitive athletes.

• Health-related Fitness: Physical activity with the objective of reducing the risk of chronic disease, muscular fitness, and overall well-being.

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Definitions

• Baseline Activity: Light-intensity activities of daily living, including standing, walking slowly, lifting lightweight objects, and climbing stairs.

• Physical Activity: Planned, structured, repetitive activities with the objective of improvement and maintenance of physical fitness.

Presenter
Presentation Notes
There is inadequate evidence to prove health benefits of increasing baseline activities. Rationale for increasing at least baseline lifestyle activities - maintain healthy body weight - improve bone health - walking instead of driving to decrease traffic congestion - build culture of physical activity - appropriate for people who are sedentary, or limited by chronic conditions
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Definitions

Physical Activity Intensity Health Benefits Comment

Inactive Baseline activity None Unhealthy

Low < 150 min/week Some Minimum

Medium 150 – 300 min/week Substantial Incremental benefits

High > 300 min/week Additional

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Health Benefits of Physical Activity

• Cardiovascular Disease and Overall Mortality • Diabetes and Other Metabolic Disorders • Mental and Neurological Health • Bone, Joint, Muscular Health

Lucas Cranach the Elder, 1546

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All-Cause Mortality

• Age > 60 years – Risk for all-cause mortality decreases by fitness level

• Age > 80 years – Death rate among ‘high fitness’ men lower than least

fit men age 60 – 69 years • Association persists after correction for weight

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Cardiovascular Disease

Presenter
Presentation Notes
Based on a study of middle-aged adults, showed that all cause and CVD mortality rates were 60% lower in persos with moderate vs low cardiorepiratory fitness, estimated from time to fatigue on a treadmill tests; adults of moderate fitness in this study reported a weekly energy expenditure in moderate-intensity physical activity of 8-9 MET * h / wk
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Cardiovascular Disease

• Hypertension

• Event-free survival

• Decreased CVD death rate

• CVD events in asymptomatic men

• Sudden cardiac death in women

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Cancer

• Decreased risk of developing cancer • Decreased risk of recurrence • Decreased risk of death • Reduced cancer fatigue

• Association persists after correction for weight

Presenter
Presentation Notes
Women with breast cancer have demonstrated decreased mortality and risk of recurrence with physical activity. Physical activity has been associated with decreased risk of developing cancer, including lung CA.
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Cancer

• Cooper Center Longitudinal Study

Presenter
Presentation Notes
Prospective, observational cohort study 13,949 men, cardiorespiratory fitness levels assessed between 1971 and 2009 based on treadmill exercise test (Balke protocol) Incidence of Ca was measured with medicare claims data from 1999 to 2009 There is an inverse association between midlife CRF and incident lung / colorectal cancer but not prostate cancer. High midlife CRF is associated with lower risk of cancer related death and cardiovascular mortalitiy in those diagnosed as having cancer at medicare age. Figure shows the risk of incident lung/colorectal / prostate ca, the low CRF group is the referent group relative to moderate and high fitness groups
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Cancer

Presenter
Presentation Notes
Journal of the National Cancer Institute – next month In a new study involving mice, aerobic exercise slowed the growth of breast cancer tumors and made the cancer more sensitive to chemotherapy. The results raise the possibility that exercise may change the biology of some malignant tumors, potentially making them easier to treat. Next, using another group of mice with breast cancer, the scientists had a quarter of the animals remain sedentary. Another quarter of the animals ran on wheels. A third group received a standard drug used in chemotherapy treatment of breast cancer while remaining sedentary. And the final group exercised and received the chemotherapy drug. Exercise statistically significantly reduced tumor growth and was associated with a 1.4-fold increase in apoptosis (sedentary vs exercise: 1544 cells/mm(2), 95% CI = 1223 to 1865 vs 2168 cells/mm(2), 95% CI = 1620 to 2717; P = .048), increased microvessel density (P = .004), vessel maturity (P = .006) and perfusion, and reduced intratumoral hypoxia (P = .012), compared with sedentary controls. However the mice that simultaneously had exercised and received chemotherapy showed the best outcome, with the smallest tumors by a significant margin. That result suggests, Dr. Dewhirst says, that exercise had made the breast cancer tumors in the mice more amenable to the chemotherapy. By making the tumors less hypoxic — and paradoxically healthier, he says — exercise “also had made those tumors easier to kill.”
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Diabetes Mellitus

• Epidemiology – Affects 21 million Americans (7% of the

population) – Majority have type 2 diabetes

• Associated medical conditions – Blood lipid abnormalities – Hypertension – Cardiovascular disease

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Diabetes Mellitus

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Weight Management

Physical Activity

Energy Expenditure

Negative Energy Balance

Weight Loss

• Weight loss with physical activity alone is quite small

• Activity required to maintain weight loss is higher than many realize

• Combination of diet + activity more effective

Presenter
Presentation Notes
Example of small effect of PA: 900 – 1500 kcal per week lead to 1 – 1.4kg weight loss over 11 – 16 weeks Example of diet + exercise: deficit of 500 – 700 kcal per day produced 6.5 – 8% weight loss over 12 weeks Physical activity required to maintain substantial weight loss is more than 2,500kcal/week (300 minutes / week). Less activity is required for patients who have not recently lost weight.
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Mental Health

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Mental Health

• Anxiety & Depression

– less likely

– less severe

– fewer symptoms

– dose-dependent

Presenter
Presentation Notes
Prolonged rhythmic exercise may activate the opioid system by triggering increased discharge from nerve fibers arising from contracting skeletal muscle.
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Neurological Health

• Alzheimer’s Disease – Decreased extracellular amyloid plaques

– Most studies demonstrate protective effect

– Improved cognitive performance with exercise

• Parkinson’s Disease – Questionnable protective effect

– Improved mobility, speed, and other symptoms

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Chronic Pain

• No evidence that exercise causes harm and should be avoided in chronic pain conditions

• Inactivity worsens chronic pain, back pain • PA is effective in the treatment of back pain • PA is effective in the treatment of

fibromyalgia – pain – tenderness – strength – function

Presenter
Presentation Notes
61 RCT with > 6000 patients prove effectiveness of PA in treating chronic pain. Dr. Naugle et al. (PAIN, 2017) performed a series of experiments in 51 healthy adults, aged 60 to 77. Pain modulation was significantly related to daily physical activity level. Older adults who did more moderate to vigorous physical activity perceived less facilitation of pain, while those who did at least some activity were better able to block pain perceptions. Our data suggest that low levels of sedentary behavior and greater light physical activity may be critical in maintaining effective endogenous pain inhibitory function in older adults.
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Bone Health

• Four mechanisms of the beneficial effects of physical activity: 1. Increases bone mineral accrual during

maturation 2. Decreases rate of bone mineral loss during aging 3. Enhances bone strength 4. Reduces risk of falls

Presenter
Presentation Notes
Many studies show positive effects of physical activity on bone mineral content and bone mineral density. Evidence comes from randomized controlled trials, and meta analyses of those trials. The intensity of exercise appears to be a key determinant of the osteogenic response. Four mechanisms of the beneficial effects of physical activity on reducing risk of osteoporotic fracture.
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Bone Health

• Postmenopausal women & exercise – Increased bone mineral density – Decreased fracture risk – Any type of exercise demonstrated a difference

Presenter
Presentation Notes
Nurses Health Study of 60,000 women demonstrated 50% reduction of relative risk of hip fracture over 12 year period with increased physical activty. Conversely, extreme conditions of physical inactivity or reduced mechanical loading cause rapid and profound bone loss. A meta-analysis of the effects of bed rest demonstrated that 3 weeks of bedrest doubled risk of hip fracture over next 10 years.
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Joint Health

• Knee OA – Quad strengthening reduces pain – Reduction of recurrence of pain

• Hip OA – Less evidence than for knee OA

• Running – Recreational running does not lead to OA – May be protective against development of OA – Does not apply to pre-existing OA

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Muscle Health

• Sarcopenia

– decline in skeletal muscle mass – By age 80, incidence increases to 40 – 50% – Loss of strength, power, aerobic capacity

Pathology Impairment Functional Limitation

Disability

Presenter
Presentation Notes
Sarcopenia leads to decrease in strength and power. Age > 85 has strength / power of 60% / 40% of the 20yo group. 20% men, 60% women by age 75 0 84 cannot lift bag of groceries (10lb). For older people, activities of daily living may require maximum effort.
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Muscle Health

• Increase in muscle mass • Improved function in

impaired older subjects • Improved balance • Significant decrease in

injurious falls • Age > 85, PM women

Presenter
Presentation Notes
Several randomized controlled trials have demonstrated effectiveness of resistance exercise in increasing muscle mass. Several systematic reviews have demonstrated effectiveness of progressive resistance strengthening on improved functional limitations and disability. Activities included standing from seated position, walking, and stair climbing. Physical activity, with a combination of strengthening and balance exercises reduce falls in older individuals by 40%.
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Guidelines

Presenter
Presentation Notes
American College of Sports Medicine first introduced physical activity guidelines in 1975. - recommended at least 20min of exercise per day, 3 – 5 days per week - gradual decrease in recommended intensity (70% heart rate range to 40% by 1991) In 1992, AHA declared that physical activity was major risk factor for CVD. CDC and ACSM developed and jointly released recommendation of at least 30min of MIPA per day, every day. (1995) - novel concept of moderate intensity physical activity - novel concept of short bouts of activity per day - DHHS and NIH guidelines are essentially the same as CDC/ACSM (1996) IOM guidelines (2002, 2005) increased daily physical activity requirement to 60 minutes of MIPA.
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Moderate Intensity Physical Activity

• Borg Rating of Perceived Exertion

• Heart Rate

• MET

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Borg Scale

Presenter
Presentation Notes
Introduced by Gunner Borg in 1970. A relative scale that matches how hard you feel you are working with numbers from 6-20. Simple way to estimate heart rate, by multiplying Borg score by 10. Moderate activities register 11 to 14 on the Borg Scale.
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Heart Rate

Presenter
Presentation Notes
For moderate-intensity physical activity, a person's target heart rate should be 50 to 70% of his or her maximum heart rate. This maximum rate is based on the person's age. An estimate of a person's maximum age-related heart rate can be obtained by subtracting the person's age from 220. For example, for a 50-year-old person, the estimated maximum age-related heart rate would be calculated as 220 - 50 years = 170 beats per minute (bpm). The 50% and 70% levels would be: 50% level: 170 x 0.50 = 85 bpm, and 70% level: 170 x 0.70 = 119 bpm Thus, moderate-intensity physical activity for a 50-year-old person will require that the heart rate remains between 85 and 119 bpm during physical activity.
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MET

Presenter
Presentation Notes
A physiologic measure expressing the energy cost of physical activities. Defined as the ratio of metabolic rate and energy consumption during a specific physical activity to a reference metabolic rate. 1 MET = resting metabolic rate = average person seated at rest. Moderate intensity physical activity = 3-6 (cycling, walking, calisthenics)
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Exercise Safety: Risk

• Any movement increases the risk for injury

• Running and vigorous sports are higher risk

• Past physical activity is protective

• Higher level of fitness is protective

• A sedentary lifestyle is higher risk

Presenter
Presentation Notes
Active individuals may have lower occurrence of overall injury. Recreational and competitive runners have a high prevalence of injury
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Exercise Safety: Risk

• Sudden cardiac arrest is more common during exercise than with sedentary activities

• The risk of cardiovascular adverse effects goes down with habitual activities

• The relative risk of sudden cardiac death during vigorous exercise is lowest with regular exercise.

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Exercise Safety: Prevention

• Choose activities wisely

• Moderate the total dose of physical activity

• Combine strengthening with aerobic exercise

• Maintain a normal body weight

• Improve fitness level slowly

• Obtain appropriate care and rehabilitation after injury

Presenter
Presentation Notes
Walking poses 50 percent less risk than does running. Exercising more than 20 miles per week increases the risk 1.7 to 2.1 times. Strength training reduces the risk about 40 percent in women. Although it is not known if weight loss reduces the risk of injury, it improves biomechanics. Military data show the importance of this approach. Previous injury is a risk factor for a future injury.
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Compliance

Farrance et al. 2016

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THANKS

www.facebook.com/ONSMD @ONSMD

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