EXERCISE A strong PILL in Chronic Disease Management

2. Outline: Early studies on connection between level of Physical activity and risk of Heart attacks and Mortality rates Quest for Holy Grail of Fitness Reality of Aging and Chronic Diseases Role of Exercise in treatment of 4 leading Chronic diseases: Heart Disease, Stroke, COPD, and Diabetes

3. Early 20th Century Era of Infectious Diseases: Small Pox, Polio, Pneumonia, Diphtheria High Infant Mortality Tuberculosis, Typhoid Average life expectancy 47 years (1 in 10 newborn died) (1 in 10 newborn died)

5. Died age 93Died age 93

7. Reality of Aging Aging is a natural process – we all age: but we all age differently Burden of Chronic Disease, genetics, environment, SES, stress and Level of Fitness influence the aging process

9. Burden of Chronic Disease Almost two-thirds of Ontarians over the age of 45 have a chronic disease, and of those, about 55% suffer from two or more The costs of chronic disease are estimated at 55% of the total and indirect health care costs in Ontario. So this is a big problemSo this is a big problem

12. Low level of Fitness Related to many health conditions

14. Causes of Death in Ontario 2006-2008 On this slide, you can see the 4 major causes of death in Ontario in 1999 based on Ministry of Health and Long-Term Care data But….. On this slide, you can see the 4 major causes of death in Ontario in 1999 based on Ministry of Health and Long-Term Care data But…..

15. Real Causes of Death  Yet, when we look at the underlying causes, we see that tobacco is responsible for approximately 20% of deaths, and poor diet and lack of exercise another 21% or so. Yet, when we look at the underlying causes, we see that tobacco is responsible for approximately 20% of deaths, and poor diet and lack of exercise another 21% or so.

16. Heart Disease #1 Killer worldwide 12 million deaths /year Apart from aging and Genetics Most Risk Factors are controllable: Smoking Hypertension High Cholesterol Diabetes Obesity Physical Inactivity

17. Quest for Holy Grail of Fitness and its relationship to mortality

18. Birth of Aerobic Doctrinein 60s VO2Max: A measure of Fitness -Maximum amount of Oxygen that muscles can consume during endurance exercise (Exercise Bike or treadmill). The scientific study of exercise blossomed in the 1960s and 1970s. Its principal research tool was the maximum oxygen uptake test, which measures the amount of oxygen taken up by the lungs, pumped by the heart, and delivered to the muscles during maximal exertion on a treadmill or bicycle ergometer. Improvements in the maximum oxygen uptake, or VO2 max, quickly became the gold standard for judging the efficacy of exercise. In 1975, the American College of Sports Medicine issued its first exercise guidelines. They called for all healthy adults to exercise at aerobic intensity (60% to 90% of maximum) continuously for 20-30 minutes at least 3 times a week. These standards were soon adopted with only minor modification by the American Heart Association and the US Department of Health, Education, and Welfare, and they remained in effect for more than 2 decades.The scientific study of exercise blossomed in the 1960s and 1970s. Its principal research tool was the maximum oxygen uptake test, which measures the amount of oxygen taken up by the lungs, pumped by the heart, and delivered to the muscles during maximal exertion on a treadmill or bicycle ergometer. Improvements in the maximum oxygen uptake, or VO2 max, quickly became the gold standard for judging the efficacy of exercise. In 1975, the American College of Sports Medicine issued its first exercise guidelines. They called for all healthy adults to exercise at aerobic intensity (60% to 90% of maximum) continuously for 20-30 minutes at least 3 times a week. These standards were soon adopted with only minor modification by the American Heart Association and the US Department of Health, Education, and Welfare, and they remained in effect for more than 2 decades.

19. Birth of Aerobic Doctrinein 60s VO2Max: A measure of Fitness -Expressed as ml of O2 consumed /Kg body weight/minute e.g 35ml/Kg/min As a MET number divided by 3.5 i.e 35ml/Kg/min=10METS -Gold standard for judging efficacy of Exercise and level of Fitness The scientific study of exercise blossomed in the 1960s and 1970s. Its principal research tool was the maximum oxygen uptake test, which measures the amount of oxygen taken up by the lungs, pumped by the heart, and delivered to the muscles during maximal exertion on a treadmill or bicycle ergometer. Improvements in the maximum oxygen uptake, or VO2 max, quickly became the gold standard for judging the efficacy of exercise. In 1975, the American College of Sports Medicine issued its first exercise guidelines. They called for all healthy adults to exercise at aerobic intensity (60% to 90% of maximum) continuously for 20-30 minutes at least 3 times a week. These standards were soon adopted with only minor modification by the American Heart Association and the US Department of Health, Education, and Welfare, and they remained in effect for more than 2 decades.The scientific study of exercise blossomed in the 1960s and 1970s. Its principal research tool was the maximum oxygen uptake test, which measures the amount of oxygen taken up by the lungs, pumped by the heart, and delivered to the muscles during maximal exertion on a treadmill or bicycle ergometer. Improvements in the maximum oxygen uptake, or VO2 max, quickly became the gold standard for judging the efficacy of exercise. In 1975, the American College of Sports Medicine issued its first exercise guidelines. They called for all healthy adults to exercise at aerobic intensity (60% to 90% of maximum) continuously for 20-30 minutes at least 3 times a week. These standards were soon adopted with only minor modification by the American Heart Association and the US Department of Health, Education, and Welfare, and they remained in effect for more than 2 decades.

22. We studied a total of 6213 consecutive men referred for treadmill exercise testing for clinical reasons during a mean (±SD) of 6.2±3.7 years of follow-up. Subjects were classified into two groups: 3679 had an abnormal exercise-test result or a history of cardiovascular disease, or both, and 2534 had a normal exercise-test result and no history of cardiovascular disease. Overall mortality was the end point. Being Fit associated with a > 50% Risk Reduction. After adjustment for age, the peak exercise capacity measured in metabolic equivalents (MET) was the strongest predictor of the risk of death among both normal subjects and those with cardiovascular disease. Absolute peak exercise capacity was a stronger predictor of the risk of death than the percentage of the age-predicted value achieved, and there was no interaction between the use or nonuse of beta-blockade and the predictive power of exercise capacity. Each 1-MET increase in exercise capacity conferred a 12 percent improvement in survival. Exercise capacity is a more powerful predictor of mortality among men than other established risk factors for cardiovascular disease. We studied a total of 6213 consecutive men referred for treadmill exercise testing for clinical reasons during a mean (±SD) of 6.2±3.7 years of follow-up. Subjects were classified into two groups: 3679 had an abnormal exercise-test result or a history of cardiovascular disease, or both, and 2534 had a normal exercise-test result and no history of cardiovascular disease. Overall mortality was the end point. Being Fit associated with a > 50% Risk Reduction. After adjustment for age, the peak exercise capacity measured in metabolic equivalents (MET) was the strongest predictor of the risk of death among both normal subjects and those with cardiovascular disease. Absolute peak exercise capacity was a stronger predictor of the risk of death than the percentage of the age-predicted value achieved, and there was no interaction between the use or nonuse of beta-blockade and the predictive power of exercise capacity. Each 1-MET increase in exercise capacity conferred a 12 percent improvement in survival. Exercise capacity is a more powerful predictor of mortality among men than other established risk factors for cardiovascular disease.

23. Protective Effect of Fitness in Different Conditions

24. Survival of the Fittest In 1859, Charles Darwin published his theory of evolution as an incessant struggle among individuals with different degrees of fitness within a species. Now, nearly 150 years later, in the era of evidence-based medicine and rigorous scientific method, when fitness is measured and study subjects are followed for years, the data supporting the concept of survival of the fittest are strong and compelling

25. Medical and Technological advances in Cardiovascular Medicine: 30% reduction in death rates from acute myocardial infarction Over 200% increase in cost component of Health Care System Cardiovascular Drug Expenditure Prediction: >10.6 billion by 2020

26. Effects of Recent Advances may be short lived! More Canadians esp those >50yrs age have higher rates of Diabetes, Hypertension, High Cholesterol, Obesity Increase in Heart Disease expected as the population grows older

27. Importance of Risk Factor Management By Lifestyle Changes

28. Getting Fitter through Cardiac Rehab has its benefits

30. Stroke Rehab Of every 100 people who have stroke : 15 succumb in acute phase 10 recover completely 25 recover with minor impairment or disability 40 are left with moderate to severe disability 10 severely impaired ,require long term care Deconditioning compromises physical independence and quality of life Stroke is the number one cause of long-term adult disability ?? Total number of stroke survivors is increasing ?? 60% of stroke survivors have residual motor impairments that may limit physical activity ?? Deconditioning compromises physical independence an Stroke is the number one cause of long-term adult disability ?? Total number of stroke survivors is increasing ?? 60% of stroke survivors have residual motor impairments that may limit physical activity ?? Deconditioning compromises physical independence an

31. Stroke Rehab Decreased physical activity severely decreases VO2 Stroke survivors have a 30-40% lower aerobic capacity than age-matched persons Stroke survivors have to work harder at a higher relative intensity to complete the same functional tasks Increased energy demands secondary to stroke related deficits Low VO2 + increased energy demands = decreased functional capacity

32. Aerobic Training in Chronic Stroke 1. Improves fitness 2. Improves glucose metabolism 3.Improves cardiac profile 4. Improves walking function 5. Enhances Quality of Life 5. Locomotor gains linked to brain plasticity (The Brain that changes itself : Norman Doidge)

33. Effect of Aerobic training

34. CHRONIC OBSTRUCTIVE PULMONARY DISEASE COPD is generally a silent and unknown killer in Canada, and threatens to be one of the main causes of disability and death in the new millennium. COPD is the fourth leading cause of death for men and seventh for women (LCDC, Health Canada); A rapidly advancing disease – the number of deaths from COPD has quadrupled since 1971, and, while it is projected that male mortality will begin to stabilize into 2016, female estimates show a triple-fold increase between 1996 and 2016. Expected to be the 3rd leading cause of death worldwide by 2020.

35. CHRONIC OBSTRUCTIVE PULMONARY DISEASE ECG of COPD: Diagnosing Airflow obstruction Flow Volume Loop

38. Components of Lung Rehab ! How to control breathing when short of breath Pursed Lip Breathing Diaphragmatic Breathing Aerobic exercises and Resistance training Reducing isolation/anxiety Nutritional needs Using medications effectively Need for Oxygen Remaining a non-smoker

39. Inspiratory Muscle Training Combined with General Exercise Reconditioning in Patients with COPD Respiratory muscle strength 15% increased strength 33% increased endurance 12 minute walking distance 21% increase in exercise BUT little change in Lung Function on measurement

41. Latin American Countries Su bSahara AfricaLatin American Countries Su bSahara Africa

42. Diabetes:A Man Made Disease Prevention is possible

43. DPP, participants from 27 clinical centers around the United States were randomly divided into different treatment groups. The first group, called the lifestyle intervention group, received intensive training in diet, physical activity, and behavior modification. By eating less fat and fewer calories and exercising for a total of 150 minutes a week, they aimed to lose 7 percent of their body weight and maintain that loss.DPP, participants from 27 clinical centers around the United States were randomly divided into different treatment groups. The first group, called the lifestyle intervention group, received intensive training in diet, physical activity, and behavior modification. By eating less fat and fewer calories and exercising for a total of 150 minutes a week, they aimed to lose 7 percent of their body weight and maintain that loss.

44. Role of Exercise in Treatment of Diabetes

45. Structured Exercise Training and Fitness Changes in Type 2 DM N=9 RCTs; 266 subjects 40% women, mean age 55.7 average duration of DM was 4.1 years average exercise program: 49 mins x 3.4 x per week Duration >8 weeks (avg 20 wks) Exercise intensity 50% to 75% of VO2max  UNIVERSITY OF OTTAWA Systematic review and meta-analysis of randomized controlled clinical trials evaluating the effects of structured aerobic exercise interventions of 8 weeks or more on CR fitness in adults with Type 2 (up to and including year 2002) pooled N = 266 7 AT studies -3.4 times/wk, 49 minutes per session for 20 weeks -intensity ranged from 50-75% of VO2max Weighted mean differences in A1C of -0.71 in the exercise groups (from the 2001 JAMA article) MECHANISMS FOR LOW VO2 AT BASELINE IR is associated with many abnormalities in muscle tissue including (POOR UTILIZATION): -increase muscle lipid content -impaired glycogen synthesis -increase in anaerobic enzymes (PFK/CS ratio) -increase in type II muscle fibres OR -Oxygen delivery (decreased cardiac output, decrease in capillary density) EXERCISE HELPS BY: -post-insulin Rc signaling cascade -increase glucose delivery and use by increased capillary density -increase glycogen synthase and HK activity -increase GLUT 4 activity -decrease release of FFAUNIVERSITY OF OTTAWA Systematic review and meta-analysis of randomized controlled clinical trials evaluating the effects of structured aerobic exercise interventions of 8 weeks or more on CR fitness in adults with Type 2 (up to and including year 2002) pooled N = 266 7 AT studies -3.4 times/wk, 49 minutes per session for 20 weeks -intensity ranged from 50-75% of VO2max Weighted mean differences in A1C of -0.71 in the exercise groups (from the 2001 JAMA article) MECHANISMS FOR LOW VO2 AT BASELINE IR is associated with many abnormalities in muscle tissue including (POOR UTILIZATION): -increase muscle lipid content -impaired glycogen synthesis -increase in anaerobic enzymes (PFK/CS ratio) -increase in type II muscle fibres OR -Oxygen delivery (decreased cardiac output, decrease in capillary density) EXERCISE HELPS BY: -post-insulin Rc signaling cascade -increase glucose delivery and use by increased capillary density -increase glycogen synthase and HK activity -increase GLUT 4 activity -decrease release of FFA

46. Comprehensive Chronic Disease Care Model STENO-2 Trial Randomized trial of diabetes care intensive risk factor care Diet + Exercise Vs. Usual care 8 year follow-up mean age 55(27%W) Composite endpoint CVD death Nonfatal MI and/or stroke Revascularization or amputation The patient population only included white Danes The overall sample size of 160 is relatively small(*0 Control+80 intensive) NPH and regular insulin are arguably inferior to glargine and ultra-short acting insulins in terms of risk of complications and stable management of blood glucoseThe patient population only included white Danes The overall sample size of 160 is relatively small(*0 Control+80 intensive) NPH and regular insulin are arguably inferior to glargine and ultra-short acting insulins in terms of risk of complications and stable management of blood glucose

47. Physicians and their Patients 47% of primary care physicians include an exercise history as part of their initial examination (self report) Only 13% of patients report physicians giving advice about exercise

50. Fall in Muscle Mass and VO2 can be reversed to prevent effects of Chronic Diseases and live better… “ Fitter” !

52. Can one get Younger and Fitter at any age ?

53. Seniors age 60-81 32 Exercise grp 33 ControlsSeniors age 60-81 32 Exercise grp 33 Controls

54. Seniors age 60-81 32 Exercise grp 33 ControlsSeniors age 60-81 32 Exercise grp 33 Controls

56. We need to be flexible in how we look at the elderly!