Steven N. Blair Departments of Exercise Science & Epidemiology/Biostatistics

1. Exercise Is Medicine—Putting Science in to Clinical PracticePreventive Medicine 2010Arlington, VAFebruary 18, 2010 Steven N. Blair Departments of Exercise Science & Epidemiology/Biostatistics University of South Carolina

2. Disclosures • Medical/Scientific Advisory Boards • Jenny Craig, Inc • Alere • Technogym • Research Funding • NIH • Body Media • Coca Cola • Swimming Pool Foundation

3. Exercise Is Medicinewww.exerciseismedicine.orgExercise Is Medicine World Congress Baltimore, MDJune 1-3, 2010

4. Dr. & Mrs. Jerry Morris with Brad Pitt

5. Aerobics Center Longitudinal Study

6. Design of the ACLS 1970 More than 80,000 patients 2005 Cooper Clinic examinations--including history and physical exam, clinical tests, body composition, EBT, and CRF Mortality surveillance to 2003 More than 4000 deaths 1982 ‘86 ‘90 ‘95 ’99 ‘04 Mail-back surveys for case finding and monitoring habits and other characteristics

7. All-Cause Death Rates by CRF Categories—3120 Women and 10 224 Men—ACLS Blair SN. JAMA 1989

8. Cardiorespiratory Fitness, Risk Factors and All-Cause Mortality, Men, ACLS # of risk factors Risk Factors current smoking SBP >140 mmHg Chol >240 mg/dl Cardiorespiratory Fitness Groups *Adjusted for age, exam year, and other risk factors Blair SN et al. JAMA 1996; 276:205-10

9. CRF and Risk of Incident Hypertension, ACLS Women • 4,884 healthy women examined at the Cooper Clinic, 1970-1998 • 157 women developed hypertension during average follow-up of 5 years • Risk adjusted for age, exam year, alcohol intake, smoking, BP, family history of hypertension, waist girth, glucose, & triglycerides Risk of Developing Hypertension P for trend <0.01 Fitness Groups Barlow CE et al. Am J Epidemiol 2006; 163:142-50

10. CRF and Digestive System Cancer Mortality 38,801 men, ages 20-88 years 283 digestive system cancer deaths in 17 years of follow-up CRF was inversely associated with death after adjustment for age, examination year, body mass index, smoking, drinking, family history of cancer, personal history of diabetes Fit men had lower risk of colon, colorectal, and liver cancer deaths High Fit Moderately Fit Low Fit Peel JB et al. Cancer Epidemiol Biomarkers Prev2009; 18:1111

11. CRF and Breast Cancer Mortality Odds Ratio 14,551 women, ages 20-83 years Completed exam 1970-2001 Followed for breast cancer mortality to 12/31/2003 68 breast cancer deaths in average follow-up of 16 years Odds ration adjusted for age, BMI, smoking, alcohol intake, abnormal ECT, health status, family history, & hormone use p for trend=0.04 Sui X et al. MSSE 2009; 41:742

12. Activity, Fitness, and Mortality in Older Adults

13. Cardiorespiratory Fitness and All-Cause Mortality, Women and Men ≥60 Years of Age • 4060 women and men ≤60 years • 989 died during ~14 years of follow-up • ~25% were women • Death rates adjusted for age, sex, and exam year All-Cause death rates/1,000 PY Age Groups Sui M et al. JAGS 2007.

14. Cardiorespiratory Fitness and Risk of Dementia, ACLS • 59,960 women and men • Followed for 16.9 years after clinic exam • 4,108 individuals died • 161 with dementia listed on the death certificate • Hazard ratio adjusted for age, sex, exam yr, BMI, smoking, alcohol, abnormal ECG, history of hypertension, diabetes, abnormal lipids, and health status Hazard Ratio P for trend=0.002 Fitness Categories Lui R et al. Research in progress

15. Multivariate + % Body Fat adjusted HR of All-Cause Mortality by Fitness Groups, ACLS, 2603 Adults 60+ Adjusted HR p for trend <0.001 106 deaths 98 deaths 95 deaths 90 deaths 61 deaths Cardiorespiratory Fitness *Adjusted for age, exam year, smoking, abnormal exercise ECG, baseline health conditions, and percent body fat Sui M et al. JAMA 2007; 298:2507-16

16. Cardiorespiratory Fitness and Health Outcomes in Various Population SubgroupsSuch as People Who Are Overweight or Obese

17. CVD Mortality Risk* by Fitness and BMI Categories, 2316 Men with Diabetes, 179 CVD Deaths p for trend <0.0001 p for trend <0.002 p for trend <0.0001 Church TS et al. Arch Int Med 2005; 165:2114 *Adj for age and examination year

18. Joint Associations of CRF and % Body Fat with All-cause Mortality, ACLS Adults 60+ Death rate/1,000 person-years Deaths 151190 29 72 Rates adjusted for age, sex and exam year Sui M et al. JAMA 2007; 298:2507-16

19. Muscular Strength and Mortality

20. Strength, Adiposity, and Cancer Mortality Odds of Cancer Death* 8,677 men, 20-82 years 18.8 years of follow-up, 211 cancer deaths Muscular strength assessed by 1-RM bench press and leg press Significant trend across strength categories remained after further adjustment for BMI, % body fat, waist circumference, and cardiorespiratory fitness P for trend=0.003 Thirds of Strength Ruiz J et al. Cancer Epidemiol Biomarkers Prev 2009; 18:1468 *Adj for age, exam yr, smoking alcohol intake, and health status

21. Yes, But Those Are Observational Studies, and We Require Randomized Clinical Trial Evidence

22. Change in Physical Health Martin CK et al. Arch Int Med 2009; 169:269-78

23. Change in Mental Health Martin CK et al. Arch Int Med 2009; 169:269-78

24. Change in Energy Martin CK et al. Arch Int Med 2009; 169:269-78

25. Reduction in Risk of Developing Diabetes in Comparison with Controls, DPP 100 *Moderate intensity exercise of 150 min/week; low calorie, low fat diet 80 58% 60 Risk reduction (%) 40 31% 20 0 Lifestyle Intervention* Metformin DPP Research Group. NEJM 2002; 346:393-403

26. Cost Effectiveness of Diabetes Prevention-DPP • The lifestyle and metformin groups cost $2,250 more/year than placebo • As implemented in the DPP and from a societal perspective, lifestyle was more cost effective than metformin DPP Res Group. Diab Care 2003; 26:2518

27. Summary

28. Gain in Longevity for a 45-Year Old Male Years of added life Comparison of Low, Moderate, and High Fitness Levels

29. Health Care Overview Medical care costs in the U.S are ~17% of GNP, by far the highest in the world By traditional public health markers such as longevity, chronic disease rates, infant mortality, etc; the U.S. ranks far behind many other countries Most health problems are the result of unhealthy lifestyles We must be more aggressive in integrating lifestyle interventions into medical practice and public health programs

30. Behavioral Approaches to Physical Activity Interventions • Theoretical foundations • Social Learning Theory • Stages of Change Model • Environmental/Ecological Model • Methods • Problem solving • Self-monitoring • Goal setting • Social support • Cognitive restructuring • Incremental changes • Manipulating the environment

31. Lessons Learned from Physical Activity Intervention Studies • Individuals who use cognitive and behavioral strategies are more likely to be active at 24 months than individuals who do not use these strategies • Approximately 25-30% of initially sedentary persons who participate in Active Living will be meeting consensus public health guidelines for physical activity at 24 months

32. How to Achieve Lifestyle Change Counseling by a PhD level behavioral psychologist Counseling by B.A. level health educators Counseling by mail and telephone Counseling by electronic communications

33. Lifestyle Interventions Integrated with Electronic Health Records—Kaiser Permanente

34. Exercise as a Vital Sign Kaiser Permanente Within the Visit Navigator, you will now see the “Exercise Vitals” section immediately following the “Vitals” section.

35. Exercise as a Vital Sign Kaiser Permanente When you click on the “Exercise Vitals” the section opens up to display the two exercise intake questions that can be completed in a quick manner. The date and time this data was captured will also be noted/stored.

36. Telehealth and Weight Change Kg change at 6 mo 87 participants (73 women & 14 men) Mean age 50 years Treatment groups (Quasi-experimental design) Traditional class Telehealth—interaction with RD via web and email Control No difference in satisfaction between traditional and telehealth Telehealth more convenient than traditional (p<0.0001) p <0.05 Traditional Telehealth Control Haugen HA et al. Obes 2007; 15:3067-77

37. Promoting PA via PDA • 37 healthy, inactive adults, ≥50 years of age • 8-week RCT • PDA intervention (93% had not used PDAs) • Questions about amount and type of PA • Alerted at 2 PM and 9 PM to complete PA assessment • Gave motivational and behavioral tips • Controls—standard written materials King AC et al. Am J Prev Med 2007; 34:138-42

38. Promoting PA via PDA • Intervention participants completed 68% of the 112 PDA entries available • After adjusting for baseline differences • PDA group reported 310.6 minutes of moderate to vigorous PA/week • Control group reported 125.5 minutes/week • p=0.048 for group comparison • 78.6% of PDA group reported enjoying using the device King AC et al. Am J Prev Med 2007; 34:138-42

39. Summary Unhealthful lifestyles are the major cause of chronic disease morbidity and mortality Lifestyle interventions have demonstrated efficacy and effectiveness in a variety of populations Our challenge now is to develop translational interventions, using modern technology, to reach large numbers of individuals at a low cost.

40. Thank you