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Exercise a s Medicine. Instructor of Medicine Department of Medicine Division of Sports Medicine Northwestern University Feinberg School of Medicine. Exercise as Medicine. The Scope of the Problem Health Benefits of Physical Activity and Exercise

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    1. Exercise as Medicine Instructor of Medicine Department of Medicine Division of Sports Medicine Northwestern University Feinberg School of Medicine

    2. Exercise as Medicine • The Scope of the Problem • Health Benefits of Physical Activity and Exercise • Benefits of Weight Training and Muscular Fitness • How to Improve Muscular Fitness • Benefits of Flexibility Exercise • Maintaining Effects of Exercise • Prescribing Exercise • Risks of Exercise

    3. Risk Factors for Heart Disease • Family History • Cigarette Smoking • Hypertension • Diabetes/Impaired Fasting Glucose • Obesity • Sedentary Lifestyle

    4. Prevalence of Sedentary Time

    5. Obesity Trends* Among U.S. AdultsBRFSS,1990, 2000, 2010 (*BMI 30, or about 30 lbs. overweight for 5’4” person) 2000 1990 2010 No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

    6. Obesity Trends* Among U.S. AdultsBRFSS,1985 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%

    7. Obesity Trends* Among U.S. AdultsBRFSS,1986 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%

    8. Obesity Trends* Among U.S. AdultsBRFSS,1987 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%

    9. Obesity Trends* Among U.S. AdultsBRFSS,1988 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%

    10. Obesity Trends* Among U.S. AdultsBRFSS,1989 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%

    11. Obesity Trends* Among U.S. AdultsBRFSS,1990 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%

    12. Obesity Trends* Among U.S. AdultsBRFSS,1991 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

    13. Obesity Trends* Among U.S. AdultsBRFSS,1992 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

    14. Obesity Trends* Among U.S. AdultsBRFSS,1993 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

    15. Obesity Trends* Among U.S. AdultsBRFSS,1994 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

    16. Obesity Trends* Among U.S. AdultsBRFSS,1995 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

    17. Obesity Trends* Among U.S. AdultsBRFSS,1996 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

    18. Obesity Trends* Among U.S. AdultsBRFSS,1997 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20%

    19. Obesity Trends* Among U.S. AdultsBRFSS,1998 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20%

    20. Obesity Trends* Among U.S. AdultsBRFSS,1999 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20%

    21. Obesity Trends* Among U.S. AdultsBRFSS,2000 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20%

    22. Obesity Trends* Among U.S. AdultsBRFSS,2001 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

    23. Obesity Trends* Among U.S. AdultsBRFSS,2002 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

    24. Obesity Trends* Among U.S. AdultsBRFSS,2003 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

    25. Obesity Trends* Among U.S. AdultsBRFSS,2004 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

    26. Obesity Trends* Among U.S. AdultsBRFSS,2005 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

    27. Obesity Trends* Among U.S. AdultsBRFSS,2006 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

    28. Obesity Trends* Among U.S. AdultsBRFSS,2007 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

    29. Obesity Trends* Among U.S. AdultsBRFSS,2008 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

    30. Obesity Trends* Among U.S. AdultsBRFSS,2009 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

    31. Obesity Trends* Among U.S. AdultsBRFSS,2010 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

    32. Exercise Recommendations • ACSM/AHA Guidelines: • At least 150 minutes per week of moderate exercise or 75 minutes per week of vigorous exercise • 30 minutes per day, 5 times per week • Perform activities that maintain or increase muscular strength and endurance a minimum of 2 days each week Garber et al. ACSM Postion Stand on Exercise. 2011.

    33. Physical Benefits of Exercise • Decreased risk of CHD, stroke, type 2 Diabetes Mellitus, colon and breast cancers • Lowers blood pressure, improves cholesterol profile, CRP, increases insulin sensitivity • Preserves bone mass and reduces risk of falling • All-cause mortality is delayed by regularly engaging in physical activity Garber et al. ACSM Postion Stand on Exercise. 2011.

    34. Psychological Benefits of Exercise • Prevents/improves mild to moderate depressive disorders and anxiety • Lowers risk of cognitive decline and dementia

    35. Exercise Intensity • Important determinant of physiological responses to exercise training • DiPietro et al (2006): significant improvement in glucose utilization in sedentary older men and women who engaged in vigorous (80% VO2max) exercise • Not in those who performed moderate (65% VO2max) exercise DiPietro et al. J Appl Physiol. 2006.

    36. Intensity Threshold • Threshold of exercise intensity varies depending on fitness level • Higher intensity threshold for trained individuals vs. untrained individuals to improve VO2 max • Little evidence for intensity threshold for changes in HDL, LDL or TG, BP, glucose intolerance or insulin resistance Butcher LR et al. Med Sci Sports Exerc. 2002.

    37. Intensity Threshold • Several studies suggest exercise intensity does not influence magnitude of loss of body weight or fat stores • Subjects who walked at self-selected pace with fixed volume (10,000 steps/day x 3 days/wk) • Improved cholesterol profiles and expression of genes involved in reverse lipid transport • No accompanying changes in body weight and total body fat Butcher LR et al. Med Sci Sports Exerc. 2002. Butcher et al. Med Sci Sports Exerc. 2008.

    38. Patterns of Exercise • Discontinuous Exercise • Weekend Warrior • Interval Training • Sedentary Behavior

    39. Discontinuous Exercise • Moderate-intensity physical activity may be accumulated in bouts of 10 or more min each to attain goal of at least 30 min daily • Effectiveness of long vs. short bouts of exercise for improving body composition, cholesterol or mental health inconclusive • Volume of energy expended rather than the duration of exercise that is important

    40. Weekend Warrior • This pattern of exercise was associated with lower rates of premature mortality compared with being sedentary in a study of men without CV risk

    41. Interval Training • Short term (< 3 mos) has resulted in similar or greater improvements in cardiorespiratory fitness and cardiometabolic biomarkers compared to single-intensity exercise • Lipoproteins, glucose, IL-6, and TNF alpha, muscle fatty acid transport

    42. Interval Training • Study of healthy untrained men: • Interval running exercise more effective than sustained running of similar total duration in improving cardiorespiratory fitness and blood glucose concentrations • Less effective in improving resting HR, body composition and total cholesterol/HDL ratio

    43. Sedentary Behavior • Associated with elevated risk of CHD mortality, depression, increased waist circumference, elevated BP, depressed lipoprotein lipase activity and worsened chronic disease biomarkers • Glucose, insulin, lipoproteins • Detrimental even among individuals who meet current physical activity recommendations

    44. Sedentary Behavior • Amount of time spent in activities such as TV watching and sitting at a desk should be assessed • When sedentariness is broken up by short bouts of physical activity or standing, attenuation of adverse biological effects

    45. Effect of Exercise on Cardiometabolic Risk Factors • Improvement in high blood pressure, glucose tolerance, insulin resistance, dyslipidemia and inflammatory markers • Benefits of exercise on cardiometabolic risk factors are acute (hours to days) and chronic • Regular exercise participation on most days of the week is important

    46. Exercise + Diet Modification • Exercise without dietary modification has modest effect on short-term weight loss • Favorable changes in visceral abdominal fat, total body fat and biomarkers can occur even without weight reduction • Weight loss enhances these improvements

    47. Dose Response • Church et al. (2007) evaluated effect of varying exercise volumes at fixed intensity (50% VO2max) • Sedentary, overweight or obese postmenopausal women randomized to exercise volumes of 50%, 100% or 150% of recommended weekly energy expenditure • Dose-response effect across 3 volumes observed • Initial level of fitness may affect the training responses to a set volume of exercise Church TS et al. JAMA. 2007.

    48. Benefits of Weight Training and Muscular Fitness • Higher levels of muscular strength are associated with significantly better cardiometabolic risk factor profiles, lower risk of all-cause mortality, fewer CVD events, lower risk of developing functional limitations and nonfatal disease

    49. Benefits of Weight Training and Muscular Fitness • Limited data on dose-response characteristics between muscular fitness and health outcomes or existence of threshold for benefit • Muscular fitness can lead to improvements in body composition, blood glucose levels, insulin sensitivity and blood pressure in persons with pre hypertension and stage I hypertension

    50. Benefits of Weight Training and Muscular Fitness • Resistance training may be effective to prevent and treat “metabolic syndrome” • Increases bone mass and bone strength of specific bones stressed • Prevents, slows or even reverses the loss of bone mass in people with osteoporosis • Muscle weakness is a risk factor for development of osteoarthritis • Resistance training may reduce chance of developing MSK disorders