the role of physical activity in cardiometabolic health...plavix (clopidogrel) 75 mg daily – $160...
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Co-Director, Sports Medicine FellowshipKaiser Permanente Medical CenterFontana, California, USA
Robert E. Sallis, MD, FAAFP, FACSM
Chairman, Exercise Is Medicine Advisory Board
Understanding the Connection Between Physical Activity and Health
Clinical ProfessorFamily MedicineUC RiversideSchool of Medicine
The Role of Physical Activity in Cardiometabolic Health
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Genetics Environment
Behavior
What Factors Determine Our Health and Longevity?
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Leading Causes of Death in the World; 2014
CauseHeart Disease
StrokeCOPD
Lower Respiratory InfectionLung Cancers
HIV/AIDSDiarrheal Disease
DiabetesRoad Injury
Hypertension
Number7.4 Million6.7 Million3.1 Million3.1 Million1.6 Million1.5 Million1.5 Million1.5 Million1.5 Million1.3 Million
World Health Organization
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JAMA March 10, 2004
Deaths per Year in U.S. (1,000s)
Illicit use of drugs
Sexual behaviors
Incidents involving firearms
Motor vehicle crashes
Toxic substances
Microbial agents
Inactivity/Poor diet
0 50 100 150 200 250 300 350 400 450 500
Alcohol
Tobacco
Leading Actual Causes of Death in the U.S.1. Tobacco, 18.1%2. Physical inactivity and
Poor diet, 16.6%
Actual Causes of Death
17
20
29
43
55
43
85
400
435
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First generation on pace to NOT out-live their parents?
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Cardiovascular Disease (CVD) The major cause of death in developed countries. Combination of risk factors lead to CVD:
– Some of the most important ones are modifiable (inactivity, smoking, diet).
– Others less modifiable (psychosocial factors) or non modifiable (genetics, age and sex).
Physical inactivity (and low fitness) is arguably the most important.– This is not reflected by current medical practice.
– Inadequate emphasis on increasing PA.
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The Classification of Risk Factors for Cardiovascular Disease Surrogate outcomes of poor lifestyle choices and
stress (hypertension, obesity, cholesterol and diabetes), along with smoking are given “causal” risk factor status for CVD disease. Physical inactivity is generally referred to as a
“predisposing” risk factor.– Suggesting its influence on disease is entirely due to
intensification of the causal factors.– Result has been disproportionate focus on drugs (mainly
lipid and BP) to treat disease.– Research has proven this is incorrect.
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The Effect of Exercise on CVD Risk Even after accounting for traditional CVD risk factors
(BP, DM, lipids, weight), the inverse relationship between PA & CVD risk persists. – ~59% of the reduction in CVD risk with exercise is due to
reducing Inflammation & Clotting (32.6%), BP (27.1%), lipids (19.1%), BMI (10.1%), A1C (8.9%).
– 41% of risk reduction due to other unknown mechanisms (perhaps endothelium function and remodeling or LV structure and function).
– Effect of weight loss is only on traditional risk factors.
Mora, Circulation, 2007
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Even after accounting for traditional CVD risk factors (BP, DM, lipids, weight), the inverse relationship between PA & CVD risk persists. – ~59% of the reduction in CVD risk with exercise is due to
reducing Inflammation & Clotting (32.6%), BP (27.1%), lipids (19.1%), BMI (10.1%), A1C (8.9%).
– 41% of risk reduction due to other unknown mechanisms (perhaps endothelium function and remodeling or LV structure and function).
– Effect of weight loss is only on traditional risk factors.
Mora, Circulation, 2007
The Effect of Exercise on CVD Risk
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Fitness Correlates with CVD Mortality Risk*Regardless of BMI
0123456789
10
Risk
of C
VD M
orta
lity
18.5 < BMI <25.0 25.0 ≤ BMI <30.0 30.0 ≤ BMI < 35.0
Church, Arch Int Med, 2005
*2316 Men with Diabetes; 179 CVD DeathsAdjusted for age and examination year
p for trend <0.0001 p for trend <0.0001 p for trend <0.002
Normal weight Overweight Obese
Ref
eren
ce
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Patient’s deserve to know the facts…
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Unfortunately – We have systematically engineered physical activity out of our daily routine
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Hippocratesfrom his book Regimen ( 5th Century B.C.)
“Eating alone will not keep a man well; He must also take exercise. For food and exercise… work together to produce health.”
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Morris JN et al. Lancet 1953
Rate/
1000
Physical Activity at Work Prevents Coronary Artery Disease
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
Coronary Occlusion Early Mortality within 3 days of MI
Drivers Conductors31,000 London Transport Workers
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The Effect of Physical Activity on CVDPrimary and Secondary Prevention
It can help prevent the major risk factorsfor CVD. In those that have
risk factors for CVD, it can attenuate them.
It lowers mortality associated with CVD.
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Physical Activity Prevents CVD Risk Factors
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Fitness Categories
Relat
ive R
isk
Barlow CE et al. Am J Epidemiol 2006; 163:142-50
Fitness and Risk of Hypertension
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
Low Moderate High
4884 healthy women;5 yr follow-up; Controlled for BMI, age, hx of HTN
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Fitness and the Incidence of Type 2 Diabetes
0
1
2
3
4
5
6
Low Mod High
Diab
etes
incid
ence
/1000
men
Cardiorespiratory FitnessWei M et al. Ann Int Med 1999
8633 healthy U.S. men
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0
20
40
60
80
100
Ris
k re
duct
ion
(%)
*Moderate intensity exercise of ≥150 min/week; Low calorie, low fat diet
Lifestyle Intervention*
Metformin
DPP Research Group NEJM. 2002
58%
31%
Reduction in Risk of DiabetesLifestyle vs. Metformin
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The Multiple Effects of Exercise on CVD Risk Factors
Improved Lipids– Higher HDL and improved cholesterol/HDL ratio– Lower serum triglycerides
Lower blood pressure and peripheral vascular resistance Improved glucose tolerance and insulin sensitivity Reduce inflammation and clotting Improved sleep, anxiety and depression
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Physical Activity Attenuates CVD Risks
“My doctor said only 1 glass of alcohol per day –I can live with that…”
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0
2
4
6
8
10
12
14
16
18
LowModerateHigh
Controlled HTN Stage 1 HTN Stage 2 HTN Severity of HTN
P <.001 P <.001 P =.048Fitness Level
Sui X et al. Am J Hyptertension. 2007
CVD
inci
denc
e/10
00 m
an-y
rs
8147 Hypertensive Men837 CVD events
CVD Events Compared With levels of Fitness and Severity of Hypertension
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Meyers; NEJM; 2002
BMISmokingDiabetesCOPDHypertension
Relat
ive R
isk of
Dea
th
0
0.5
1
2.5
1.5
2
Exercise & Chronic Disease Mortality
< 5 METs 5-8 METs > 8 METs
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Most Importantly! Physical Activity Lowers CVD Mortality
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Fitness Correlates with CVD Death Ratesin Both Men and Women*
0
5
10
15
20
Women Men
LowModHigh
Dea
ths/
10,0
00 P
Y
*Adjusted for age, exam year and other risk factorsBlair et al. JAMA ,1996
*7,080 Women; 25,340 Men
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Fitness, CVD Risk Factors and Mortality in Men
01
2 or 3
0102030405060
Low Mod High
Dea
ths/
10,0
00 M
Y*
Blair SN et al. JAMA 1996
Risk FactorsCurrent smokerSBP >140 mmHgChol >240 mg/dl
Fitness Level*Adjusted for age, exam year, and other risk factors
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Janssen I & Jolliffe CJ. MSSE 2006
PA Lowers Mortality in CAD PatientsCardiovascular Health Study
1045 men and women ≥65 years with coronary artery disease. Followed for mortality for 9 years.
– 489 deaths in 7284 patient years of follow-up.
Physical activity assessed at baseline and at 3 years of follow-up. Shows dose-response relationship between PA and
mortality in patients with CAD.
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Change in Energy Expenditure (kcal/wk)
Relat
ive R
isk of
Mor
tality
*Adjusted for baseline activity, age, sex, race, smoking, alcohol, adiposity, comorbidities
Janssen I & Jolliffe CJ. MSSE 2006
Change in Activity and Adjusted* Risk of Death
1.25
0.5
2
1
0
0.75
1.75
1.5
-1500-2500 25005000 1500-500 1000 2000-1000-2000
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0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Exercise Angioplasty
Even
t-fre
e sur
vival
12 m
onths
Hambrecht R et al. Circulation 2004
Exercise was 20 minutes/day on a cycle ergometer
Stable CAD Exercise Training vs Angioplasty
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4 Drug Treatments for CAD Cost Comparison Plavix (Clopidogrel) 75 mg daily
– $160 per month; $1920 per year
Altace (Ramapril) 20 mg daily– $166 per month; $1992 per year
Toprol XL 400 mg daily– $170 per month; $2040 per year
Lipitor 40 mg daily– $136 per month; $1632 per year
Grand Total: $632 per month; $7584 per year
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Exercise and Quality of Life
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NEJM, April 1998
High-Risk Lifestyle (inactive, smoke, poor diet)
Quality of Life; The Geriatric Curve
Age
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NEJM, April 1998
Deficient Survival
High-Risk Lifestyle (inactive, smoke, poor diet)
The Effect of an Unhealthy Lifestyle “Deficient Survival”
Age
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NEJM, April 1998
Age
Low-Risk Lifestyle (active, non-smoker)
Deficient Survival
The Effect of a Healthy Lifestyle“Squaring off” the Geriatric Curve
“The idea is to die young as late as possible.”Ashley Montagu
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Why Has the Medical Community Neglected Physical Activity as a Treatment? Easier for physician to issue a prescription to reduce BP,
cholesterol, glucose or BMI.– Medication adherence is very low (1 in 6 take meds as prescribed).– Reliance on pills transfers responsibility for health to doctor resulting
in lower patient physical activity.
Widespread belief we cannot change physical activity habits. However:
– Evidence brief counseling and pedometer programs can increase physical activity.
– We are able to convince patients to take insulin shots, Coumadin, chemotherapy, etc – why not exercise?
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Dose-Response Curve for Exercise
Weekly Exercise Time
Bene
fit
Low HighA B C
A=SedentaryB=Moderately ActiveC=Highly Active
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What Can We Do?
World Wide Exercise Rx initiative:– Every patient; Every visit;
Every treatment plan.
Physical activity should be recorded as a vital sign and patients advised to get 30 min of mod exercise, 5 days per wk. Message should be the same from
every medical provider. We must begin to merge the
healthcare industry with the fitness industry.
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Exercise as a Vital Sign
Essential first step in moving the EIM initiative forward.– Every patient needs to be asked about their exercise
habits at every visit.– Record with BP, HR, temp, BMI and smoking history.
All Electronic Medical Records (EMR’s) need a query for exercise.– Medical assistant should ask about exercise during
patient intakes.– Must be easy to ask and record.
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Smith, John W
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Write a walking Rx for patients!
Moderate
30 minutes
5 or more
Robert Sallis, MD
John W. Smith 30
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EVS Min per week of MVPA
Risk
of A
cute
Cor
onar
y Eve
nt
Sallis. MSSE 2016; abstract
Exercise Vital Sign Correlates With Risk of an Acute Coronary Event (MI or Angioplasty)
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
0 10-149 > 150
1,423,525 adults;3yr follow-up; 9822 ACE’sControlled for BMI, age, race, smoking, Charlson index
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-7
-6
-5
-4
-3
-2
-1
0
Chan
ge fr
om M
ean A
1C
Young et al. Prev Chronic Dis; 2014
EVS 010-150>150
*369,120 Women *Controlled for age, sex, race, BMI and smoking
DBP A1CFBS
Exercise Vital Sign Correlates With Cardiometabolic Risk Factors in Women*
0
-.1
-.2
-.3
-.4
Chan
ge fr
om M
ean
BP an
d FB
S
-.5
-.6
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“At Kaiser Permanente, we want you to Live Well, Be Well and THRIVE!”
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Kaiser Permanente – “Cause”
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George HalvorsonChairman and CEO
Kaiser Health Plan and Hospitals
www.everybodywalk.org
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Vivek Murthy, MD, MBASurgeon General’s Call to Action on Walking
Washington DC September 9, 2015
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Clinicians need help!How do we integrate fitness into healthcare?
I need something beyond telling my patient to go walk! Components of fitness
– CV fitness– Strength– Flexibility
Need to be able to refer– Health Club and Fitness professional– EIM Solution
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Muscle Strength and CVD Mortality; 8762 Men*
0
2
4
6
8
10
12
14
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Middle
High
*145 CVD deaths during average follow-up of 18.9 years
Ruiz J et al. BMJ 2008
Dea
th R
ate
per 1
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0 M
Y
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Summary
Evidence is overwhelming for benefit of exercise in the primary and secondary prevention of CVD.– PA levels should be assessed at every visit using a PA
vital sign.– The “Big 3” (exercise, smoking, diet) should be
much more aggressively managed in clinical practice.– Merge fitness industry with healthcare industry.
All Healthcare Providers should prescribe exercise to patients and take it themselves. Exercise is Medicine for CVD and it’s free!
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It’s time for a change…