National Center for Chronic Disease Prevention and Health Promotion Global Health Promotion Office

1. The benefits of Physical Activity in the prevention and treatment of chronic disease: a general overview Felipe Lobelo, MD PhD FAHALead Epidemiologist Global Health Promotion Office National Center for Chronic Disease Preventionand Health Promotion - CDC National Center for Chronic Disease Prevention and Health Promotion Global Health Promotion Office

2. OBJECTIVE Daily Exercise Movement, work recreational Structured training Improve some physical characteristic Physical Activity Sport Structured training Competition

3. PA Characteristics Home Recreational and sports Intensity of the activity Domains of activity Low Means of transportation Moderate Vigorous Work/school

4. Definition of intensity

5. Fitness and mortality among NCD Patients 5-8MET (n=1885) >8MET (n=2743) <5MET (n=1585) Mortality RR History of Hipertension COPD Diabetes Smoking BMI  30 Total Cholesterol >220mg/dl N Engl J Med March 14, 2002

6. Effect of Fitness (CRF) vs “Hard” CVD risk factors on MortalityAttributable Fractions (%) for All-Cause Deaths 40,842 Men & 12,943 Women *cardio respiratory fitness Blair SN. Physical inactivity: the biggest public health problem of the 21st century. Br J Sports Med 2009; 43:1-2. Cooper Aerobics Center Longitudinal Study, 1970-2004. In progress

7. CVD risk and Fitness Quintiles among US adolescents MSz-score obtained by summing the individual risk factor age and sex-specific z-scores (sum of two SKF, logHOMA, TC/HDL, systolic BP, logTG). Quintiles of CRF are age and sex-specific Lobelo et al, Journal of Adolescent Health 2010

8. Fitness vs Fatness

14. Levels of Prevention Whole population, selected groups and healthy individuals Selected individuals with high risk; patients Patients Whole population, through public health policy PRIMORDIAL PREVENTION establish or maintain conditions to minimise hazards to health PRIMARY PREVENTION prevent disease well before it Develops Reduce risk factors SECONDARY PREVENTION early detection of disease [eg. Screening & Intervention for Pre diabetes ] TERTIARY PREVENTION treat established disease to prevent deterioration Advocacy for social change to make physically active choices easier (PE in schools, walkable communities, etc) Primary care PA advice as part of routine consultation primary care Risk factor reduction for those at risk of NCD, falls, injury exercise advice as part of cardiac rehabilitation

15. Benefits "Median" Shape of the Dose-Response Curve

16. “More is Better than Less, but Something is Better than Nothing” ACSM`s Exercise is Medicine Book

17. Benefits Physical inactivity and health Osteoporosis Weight gain prevention Disease, risk of Stroke Musculo-esqueletal injuries Functional health state Activity

18. Benefits ADULTS AND ELDERLY • Strongevidence • Lowerrisk of: • Prematuredeath • Cardiacdisease • Stroke • Diabetes mellitus type 2 • Hypertension • Dyslipidemia • Metabolicsyndrome • Breast and colon cancer • Overweightprevention • Weightreductioncombinedwithdiet • Bettercardiorespiratorycapacity • Fallprevention • Lowereddepression • Bettercognitivefunction (elders) • StrongtoModerateevidence • Betterfunctionalhealth • Less abdominal obesity • Moderateevidence • Weightstabilityafteritsreduction • Lowerrisk of hip fracture • Increasedbonedensity • Improvedsleepquality • Lowerrisk of lung and endometrial cancer

19. Primary care physicians/Nurses Role in Promoting Physical Activity • Patients receptive to information • Preferred/reliable source of health advice • Population access / potential reach • 80% of the population visits a primary care provider at least once a year. • Universal PA counseling for patients  public health impact • public health impact

20. Evidence for effectiveness of PA counseling compared to other GP interventions [Smith et al 2002; others] • Smoking advice  ≈ 5% quit rates • Alcohol advice ≈ 10-14% • Nutrition advice ≈ 5-8% change • physical activity  ≈ 10-20% change • modest effects; short term, with limited evidence for longer term effects • Investment in primary care setting interventions has potential for population health gain

21. A call for action 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

22. Risks Increase of intensity • Injuries in the musculo-skeletalsystem • Musclepain • Dehydration • Over-training • Femaleathlete triad • Myocardialinfarction • Suddendeath Risks of Physical activity

23. Risks Risk of Cardiac Arrest During Vigorous Activity and at Rest by Usual Level of Activity

24. Risks Risk of Cardiac Arrest During Activity and at Rest by Usual Level of Activity

25. Risks The health benefits of physical activity are greater than the risks. The average risk during physical activity and in rest is less in individuals that are regularly active.

26. Preventing risks • Select low risk activities   • Have a prudent behavior   • Adequate prescription of PA • Recommend activities with less strength and contact  • Do not perform excessive amounts of PA • Carry out prudent increases in the amount of PA • Be cautious with vigorous PA

27. A call for action • Every phisician must: • Review abd evaluate PA levels of each patient in every visit. • The patient must : • Receive advice on PA plans • Receive a written autorization/prescription of PA • Receive a reference to a health profesional Physical activity as a vital sign Motivate all patients so they can achieve their PA levels.

28. Healthcare staff role An Obligation for Primary Care Physicians to Prescribe Physical Activity to Sedentary Patients to Reduce the Risk of Chronic Health Conditions. Chakracarthy et al. Mayo Clin Proc 2002 Medical advice has shown to be effective to increase PA levels and reduce the risk of chronic diseases…

30. Primary care and PA Counseling • Directly provide counseling to patients to encourage recommended levels of PA • Provide brief verbal advice • Use written prescriptions • Brochures, leaflets, self-help booklets • Structured counseling, stages of change, goal setting, motivational interviewing AND / OR • Refer patients and clients to structured advice / counseling  structured programs

31. Using the practice/office as a setting for [other experts / professionals] to deliver intervention • Counseling by a nurse, physician assistant or exercise specialist in the practice • Face-to-face / telephone / mail follow-up / web • Referral to other facilities, community-based PA programs • Supervised exercise programs

32. Summary of RCTs of Exercise Referal Programs Williams NH, et al Br J Gen Pract 2007;57:979–86. • 5 of 6 RCTs used in meta analysis • Significant (20%) ↑ in OR of inactive  Moderately active • NNT =17

33. Advice in 3 minutes Adapted from ACSM`s Exercise is Medicine Book

34. Advice in 3 minutes Adapted from ACSM`s Exercise is Medicine Book

35. Be an example Main predictor for preventive counseling in physical activity given by physicians?? Gender ?? Specialty?? Age?? Time in practice?? THEIR OWN PA HABITS

36. Personal PA experience and coherence between personal habit and counseling practices makes a difference!

37.  Deaths attributed to 19 leading factors,by country income level, 2004 80% of mortality occurs in LMICWHO Global Health Risk Report 2004

38. Proportion of insufficiently active (< 150 min/week) adults worldwide • Inactivity responsible for 6% of CHD; 7% of DM; 10% Breast and Colon Cancer and • 9% of premature all-cause mortality (5.3 out of 57 million deaths in 2008) Lee IM, Shiroma EJ, Lobelo F, et al; Impact of Physical Inactivity on the World’s Major Non-Communicable Diseases; Lancet Physical Activity Series In Press

39. Global gains in life expectancy with Physical Inactivity Erradication Lee, Shiroma, Lobelo, et al 2012 The Lancet in Press

40. WHO Global Monitoring Framework Including Indicators and Global Targets For The Prevention and Control of NCDs - 2025

43. Thank you