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The goal of exercise prescription should be the successful integration of exercise principles and behavioral techniques that motivate the participant to be compliant and thus achieve their goals

Exercise prescription commonly refers to the specific plan of fitness-related activities that are designed for a specific purpose, which is often developed by the specialist for the client or patient.

Introduction

Exercise as a Prescriptive Medicine in Diseases of Civilization

Tinuade Olarewaju (MSc, B.Physio, PMP)

Physiotherapy Department, Physical Medicine Centre,

General Hospital Lagos

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Background and Data Diseases of civilization Mechanism of Exercise in specific conditions Prescription Contraindications Going forward

Today we’re going to discuss…

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What do we mean by DOC/NCD?

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UN held a high-level meeting to discuss NCD’s Prevention and Control1 in September 2011 because: 63% of all deaths in the world today result

from NCDs 36 million people die annually from NCDs 9 million young people die from NCDs

annually. 80% of NCDs deaths occur in low-and middle-

income countries

There has been a rise in the incidence of NCDs worldwide…

1 Previous meeting was called due to HIV/AIDS crisis

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NCDs caused ~38million deaths in 2008, mainly in poor countries

SOURCE: WHO 2012

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…with similar trends observed in Nigeria

In Nigeria: about 41.5% of

death resulting from NCDs occurred in individuals less than 60 years in 2008.

NCDs are estimated to account for 27% of all deaths.SOURCE: WHO 2012

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Cardiovascular diseases coronary heart diseases, Stroke, hypertensive heart

diseases, Congestive heart failure

Cancer

NCDs make up more than 15 different disease groups

ObesityChronic respiratory diseases

(COPD, occupational lung diseases and asthma)

DiabetesWRMD-arthritis, L/spondylosisMental Health

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Q & A: Modifiable and non-modifiable factors …can you change your …Age

High blood pressure

Physical Inactivity

SmokingEthnic background

High blood glucose/Diabetes

Family history of heart disease

High blood cholesterol

Overweight

Gender

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1. Type II Diabetes2. Dyslipidemia3. High blood pressure4. Obesity5. Mental health 6. Cancer

We will focus on only 6 specific conditions today

closely inter-related and co-exist; metabolic syndrome

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Condition Mechanism Prescription

1. Type II Diabetes

Sympathetic and endocrine system; increases insulin sensitivity of muscle; stimulates a mechanism independent of insulin via GLUT4

Aerobic + Rex ›Aerobic alone Aerobic + Rex › Rex alone

2. Dyslipidemia

Mediated by activation of enzymes in skeletal muscles that are necessary for lipid metabolism, strength of evidence

Weight loss + PA > Aerobic exercise alone ? Lipid lowering drugs vs exercise? Additive effect

3. High blood pressure

Neurohumoral, vascular & structural adaptation. Likely mediated via reduced sympathetically induced vasoconstriction via endothelium-derived nitric oxide in the trained state and decreased catecholamine levels.

Min 30 mins of moderate intensity exercise with short bursts of high intensity daily.

Alternate strength and endurance training.

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Condition Mechanism Prescription

4. Obesity

*BMI, Scanning,

Muscles burn fat to a greater extent instead of glycogen. Increased energy consumption, induces lipolysis, Change in post-prandial release of safety peptides, Maintain loss rather than weight loss

Diet+ Min 30 min of moderate intensity aerobic exercise plus strength conditioning Supervision, 1 hour daily.

5. Cancer ?T cells conversion, alterations in free radical generation, changes in body composition or weigh, direct effects on the tumor

Types of cancer and evidence

QoLLoss of muscle massReduced fitness

30 mins of vigorous or 60 mins moderate

6. Mental Health

↑ release of neurotransmitters, neurotrophins, which causes neurogenesis and angiogenesisAdjunct Therapy

30 minutes intensity of 60-80%; 3ce a week for 8 weeks

Beneficial effect of exercise…

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MitochondriogenesisOxidative fibre typeFatty acid oxidation

Increased aerobic capacity

Improves psychological wellbeing

Reduces anxiety and depression

Improves memory and cognitive function

Expression of neuotrophic factors

NeurogenesisQuality of sleep

Age related senility

Increases coronary blood flow Improves

cardiorespiratory fitness

↑ HDLLDL

Blood pressureBlood coagulation

Endothelial functionGlucose homeostatis

Insulin sensitivity

Reduces abdominal adiposity,

Improves weight control

Metabolic syndrome

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Take home…30 minutes minimumAny combination pill that currently

exists?

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Bend your knees and not your back If not, you might hear a ‘crack’Use the stairs and not the liftIt will make you fit and swiftTake a walk and not a ride This will keep you in good sizeDon’t sit, rise!

Rhyme Time!

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Carefully prescribedGradually progressedClosely monitored

To successfully prescribe, it should be…

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But first, let’s discuss cardiorespiratory fitness

Ability of the cardiovascular, respiratory and muscular systems to supply oxygen during prolonged physical activity

Measured by expired gas analysis or submaximal exercise tests in METS or VO2max

1MET=3.5ml/O2/kg/min

3 Health factors: untreated total choelsterol, 200mg/dL, untreated blood pressure 120/80mmHg, fasting blood glucose 100mg/dL

4 health behaviours: Non smoking, BMI <25kg/m2,PA levels, Diet

Lower CR F implicated in insulin resistance1MET=7cm,5mmhg,1mmol/L (88mg/dL),

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Carefully prescribed

Baseline screening THR=(HRmax-HRrest)

%intensity + HRrest

HRmax=208- (0.38XHRrest) VO2Max=15.3X HRmax/HRrest

Goal-weight loss? Tone Glucose control Cardio

Motivation –adherence, progression

Fitness Muscular strength Muscular endurance Flexibility Body Composition Cardiorespiratory fitness

VO2 max

HRmax

Individual

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Carefully prescribed

ACSM FIIT principle F 3-5d/wk I 20-60mins T large muscle

groups I 55/65%-90%

HRmax 40/50-85% VO2R 40-49 VO2R 55-64% HRmax

Environment

Body composition regional fat

distribution Fat free mass Fat mass

Adaptive response Peripheral Central Structural Functional

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Factors of DBPCrP Size of air pollutants

Influence of airborne pollutants on some markers of CV risk and lung function among automobile paint sprayers, cement handlers and sawmillers in Enugu metropolis

By Ibeneme Sam & Ativie rita, 2013

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Lower initial V·O2max= larger percentage of improvement found;

Higher Fat Mass (FM) = greater ↓ in total body mass and FM.

Unfit people can get significant improvements in physical fitness with a low training intensity, while those with a higher fitness level need a greater level of exercise intensity to achieve further improvements in fitness

Increasing parameters/goals

Gradually progressed…to a goal

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Caner Contraindications: Fever, active infection, Caution: anaemia-dizziness, circulation problems, dyspnoea, chest pain, tachycardia, syncopes, thrombocytopaenia1

Diabetes •Blood glucose >17mmol/L or <7mmol/L•Supervision encourages compliance and BG control •No high intensity in patients with hypertension and active proliferative retinopathy• Sudden death risk in autonomic neuropathy-silent ischemia •Caution: foot ulcers. Also, sulfonylurea, postprandial regulators or insulin to prevent hypoglycemia

Hypertension

• Caution BP > 140/90mmHg • Contraindicated > 180/105mmHg pharmacological

intervention• Caution with very intensive dynamic weights esp L

cardiac hypertrophyCoronary Heart Disease

Avoid short intensive exercise situations (Borg 15-16)Heart fibrosis in endurance/ultra-endurance athletes

Closely monitored

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Waist-hip ratio BMI Male and Female

Finally…Physiotherapy Department study

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Conclusion…Learning points NCD’s is a growing

epidemic Primary intervention

is exercise Exercise is

prescriptive Different tools are

required to measure it Collaborative

approach

Access to research and journals needed.

Need for collaborative studies with local content

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Thank you

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Pedersen & Saltin 2006. Evidence for prescribing exercise as therapy in chronic disease. Scand J Med Sci Sports: 16 (Suppl. 1): 3–63

Taylor RS, Brown A, Ebrahim S. Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials. American Journal of Medicine. 2004. 116(10) pg 682-692

Thune I, Fuberg AS. Physical activity and cancer risk: dose-response and cancer, all sites and site-specific. Med Sci Sports Exerc 2001:33:S530-S550

Westerlind KC. Physical Activity and Cancer Prevention-mechanisms Med Sci Sports Exerc 2003.35(11)pp1835-1840

Furberg, A.-S. and Thune, I. (2003), Metabolic abnormalities (hypertension, hyperglycemia and overweight), lifestyle (high energy intake and physical inactivity) and endometrial cancer risk in a Norwegian cohort. Int. J. Cancer, 104: 669–676. doi: 10.1002/ijc.10974

1. http://www.fims.org/files/3514/2056/0346/FIMS-Position-Statement-2014-Physical-activity-and-Cancer.pdf 2.

http://www.cancercouncil.com.au/wp-content/uploads/2010/09/Physical-Activity-and-Cancer-Position-Statement.pdf

4. https://www.essa.org.au/wp/wp-content/uploads/Exercise-and-Mental-Health-An-Exercise-and-Sports-Science-Australia-Commissioned-Review.pdf

5 Ridker PM. High-Sensitivity C-Reactive Protein. Potential Adjunct for Global Risk Assessment in the Primary Prevention of Cardiovascular Disease. Circulation. 2001; 103: 1813-1818. doi: 10.1161/01.CIR.103.13.1813

Leon AS, Sanchez OA. Response of blood lipids to exercise training alone or combined with dietary intervention. Med Sci Sports Exerc 2001: 33: S502–S515

Beck-Nielsen H, Henriksen JE, Hermansen K, Madsen LD, Olivarius NF, Mandrup-Poulsen TR, Pedersen OB, Richelsen B, Schmitz OE. Type 2 diabetes and the metabolic syndrome – diagnosis and treatment. 2000: 6: 1–36. Copenhagen, Lægeforeningens forlag

Saltin B, Helge JW. Metabolic Capacity of skeletal muscles and health. Ugeskr Laeger 2000:162:2159-2164

References

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6. Pescatello LS, Franklin BA, Fagard R, Farquhar WB, Kelley GA, Ray CA. American College of Sports Medicine position stand. Exercise and hypertension. Med Sci Sports Exerc 2004: 36: 533–553.

7. Gueyffier F, Boutitie F, Boissel JP, Pocock S, Coope J, Cutler J, Ekbom T, Fagard R, Friedman L, Perry M, Prineas R, Schron E. Effect of antihypertensive drug treatment on cardiovascular outcomes in women and men. A meta-analysis of individual patient data from randomized, controlled trials. The INDANA Investigators. Ann Intern Med 1997: 126: 761–767.

8. Esler M, Rumantir M, Kaye D, Lambert G. The sympathetic neurobiology of essential hypertension: disparate influences of obesity, stress, and noradrenaline transporter dysfunction? Am J Hypertens 2001: 14: 139S–146S.

9. Takenaka K, Sakamoto T, Amano K, Oku J, Fujinami K, Murakami T, Toda I, Kawakubo K, Sugimoto T. Left ventricular filling determined by Doppler echocardiography in diabetes

mellitus. Am J Cardiol 1988: 61: 1140–1143.10. Robillon JF, Sadoul JL, Jullien D, Morand P, Freychet P. Abnormalities suggestive of cardiomyopathy

in patients with type 2 diabetes of relatively short duration. Diabetes Metab 1994: 20: 473–480.11 Pradhan AD, Manson JE, Rifai N, Buring JE, Ridker PM. C-reactive protein, interleukin 6, and risk of

developing type 2 diabetes mellitus. JAMA 2001: 286: 327–334.12. Febbraio MA, Pedersen BK. Musclederived interleukin-6: mechanisms for activation and possible

biological roles. FASEB J 2002: 16: 1335–134713. Higashi Y, Sasaki S, Kurisu S, Yoshimizu A, Sasaki N, Matsuura H, Kajiyama G, Oshima T. Regular

aerobic exercise augments endothelium-dependent vascular relaxation in normotensive as well as hypertensive subjects: role of endothelium-derived nitric oxide. Circulation 1999a: 100: 1194–1202.

14 Shephard RJ (2001). Absolute versus relative intensity of physical activity in a dose-response context. Med Sci Sports Exerc 33 (6 Suppl.): S400–S418. Discussion S419–S420

References contd

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Metabolic disease characterised by Hyperglycemia and abnormal glucose, fat and protein metabolism (Beck-Nielsen et al., 2000)

Pathophysiology: Insulin resistance in the striated muscle and Beta-cell defect that prevents compensation of insulin secretion Insulin resistance causes impaired glucose tolerance (IGT)40% of IGT=Type II Diabetes

Exercise Mechanism: Resistance PA causes ↑ glucose uptake via balance between hepatic glucose production & carbohydrate for fuel.

DIABETESAlso muscular contractions transport BG via a non impaired pathway in type 2Aerobic exercises increases the effect of insulin Increases insulin receptors Acute improvements in systemic insulin action lasting from 2 to 72 h.

Recommendation: Aerobic + Rex ›Aerobic alone Aerobic + Rex › Rex alone

However: More studies needed to know if total caloric expenditure, exercise duration, or exercise mode is responsible

Evidence: ACSM 2010,

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Dyslipidemia disorder of lipoprotein metabolism. Elevated total or low-density lipoprotein (LDL) cholesterol levels or low density of High-density lipoprotein (HDL). Important risk factor for coronary heart disease & stroke.

LDL associated with atherosclerosis, fibrosis, cell death and occlusive disease ?HDL reduced atheroscelrosis (Perdersen & Saltin, 2006)

HSCRP is a strong independent predictor of future myocardial infarction and stroke among apparently healthy men and women Add HSCRP to lipid screening (5)

DYSLIPIDEMIA Possible mechanism:

Exercise enhances the ability of muscles to burn fat to a greater extent instead of glycogen. Mediated by the activation of enzymes in skeletal muscles that are necessary for lipid metabolism (Saltin & Helge, 2000) Clinically: Effect of PA is clinically relevant but < lipid-lowering drugs (Knopp, 1999). ? Additive effect

Recommendation: Weight loss + PA > Aerobic exercise alone

Evidence:Meta-analysis n=4700 (Leon& Sanchez, 2001)HDL of + 0.025mmol/L = ↓CVD risk by 2% for men ↓CVD and 3% for women (Pasternak et al., 1990; Nicklas et al., 1997).

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HHD- Diagnosed as SBP>140mmHg DBP>90mmHg

Exercise Mechanism Multifactorial such neurohumoral, vascular & structural adaptation. effect is likely mediated via reduced sympathetically induced vasoconstriction in the trained state (8) 2001), and decreased catecholamine levels.

HSCRP is a strong independent predictor of future myocardial infarction and stroke among apparently healthy men and women Add HSCRP to lipid screening (5)

Hypertensive Heart Disease(s)

Clinically: Physical training reduced systolic pressure by

7.4mmHg and diastolic by 5.8mmHg (6) which is same effect as antihypertensive agents (7)

Diastolic left ventricular dysfunction >/ PA helps left ventricular diastolic filling( 9,10,)

Also present is chronic low grade inflammation >/ induces anti-inflammatory effect (11,12)

Helps endothelium dependent vasodilatation (13)

Prescription:Minimum 30 mins of moderate intensity exercise with short bursts of high intensity daily. And alternate strength and endurance training.

Evidence: Meta-analysis; n=1Million; 61 studiesCVD death ∞↓BP till 115/75mmHg (Lewington

et al; 2002)Meta Analysis, 48 trials, 8940 patients. 6 months

duration: Reduction in all cause mortality ↓ in total cholesterol level (Taylor et al; 2003)

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Abnormally large proportion of body mass consist of fat. When energy consumption is less than energy expenditure.

Mechanism: PA increases energy consumption and induces lipolysis

? Change in post-prandial release of safety peptides for short-term appetite control

P.A causes a reduction in fat mass (FM) and visceral adipose tissue (VAT) and balances loss of muscle mass during dieting.

OBESITYClinical P.A for ↓ weight/BMI is ?? P.A has good effect on fat mass. P.A maintains weight after weight

loss

Prescription: Supervision is key to adherence For weight loss: 1 hour daily. Min 30 min of moderate intensity

aerobic exercise plus strength conditioning

Evidence: N=606; Italy; Observational 2001 Meta-Analysis (6 RCT) n=492 Obs

studies of 1 year did 1 hour a day moderate- to vigorous intensity exercise

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Uncontrolled growth of cells in the human body and the ability of the cells to migrate from the original site.

Exercise mechanismComplex -Multiple mechanisms? Stage? Individual? (Westerlind , 2003)

?immune modulation: T cells conversion ?alterations in free radical generation: Activity: low level of cell replication, increases susceptibility to ROS a.k.a free radicals. Also, anti-oxidative enzyme activity is reduced ?changes in body composition or weight direct effects on the tumor.

CANCER Clinical Effect on QoL Loss of muscle mass Reduced fitness

Recommendation:30 mins of vigorous or 60 mins moderate

Evidence: Epid study, . n=40,674 t=15yrs

Convincing: protects against colon and breast cancer. (Thune & Fuberg, 2001)

Probable evidence: reduces risk of endometrium and breast (post menopause)

Suggestive: lung, pancreatic and ovarian

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Mental Health Mechanism Evidence Recommendations

↑ release of neurotransmitters, neurotrophins, which causes neurogenesis angiogenesis & neurotransmitters.

Adjunct Therapy

Preventive: Population study 3 yrs. Dutch. 7076 adults reduced risk of mood/anxiety disorder4

Metabolic syndrome: CVD, Diabetes, weight gain risk 40%

Increased PA and physical fitness can reduce symptoms of depression and improve health-related QOL in those with type 2 diabetes.

30 minutes intensity of 60-80%; 3ce a week for 8 weeks. 4

? Adherence to higher doses. ? Exercise vs increasing PA

4-16 weeks

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Mental acuity… RCT, Sept 2014.

P-Population 221 aged 7-9 kids. I-Intervention 9 months after school PA program C-Comparison/control- wait-list control O-Outcome- (maximal oxygen consumption), electrical activity in the brain

(P3-ERP) and behavioral measures (accuracy, reaction time) of executive control using tasks that modulated attentional inhibition and cognitive flexibility

RESULTS: Improved Fitness improved in intervention group; (1.3 mL/kg per minute, 95% confidence interval [CI]: 0.3 to 2.4; d = 0.34 for group difference in pre-to-post change score). Intervention participants exhibited greater improvements from pretest to posttest

in inhibition (3.2%, 95% CI: 0.0 to 6.5; d = 0.27) and cognitive flexibility (4.8%, 95% CI: 1.1 to 8.4; d = 0.35 for group difference in

pre-to-post change score) Increased inhibition i.e. attentional resources (1.4 µV, 95% CI: 0.3 to 2.6; d = 0.34)

and cognitive flexibility (1.5 µV, 95% CI: 0.6 to 2.5; d = 0.43 CONCLUSIONS: The intervention enhanced cognitive performance and

brain function during tasks requiring greater executive control. These findings demonstrate a causal effect of a PA program on executive control, and provide support for PA for improving childhood cognition and brain health