Leading Health Indicators
1.
2.
3.
4.
5.
6.
7.
7.
9.
10.
Physical inactivity
Overweight and obesity
Tobacco use
Substance abuse
Responsible sexual behaviour
Mental health
Injury and violence
Environmental quality
Immunizations
Access to health care
US National Institute of Health
Leading Health Indicators
1.
2.
3.
4.
5.
6.
7.
7.
9.
10.
Physical inactivity
Overweight and obesity
Tobacco use
Substance abuse
Responsible sexual behaviour
Mental health
Injury and violence
Environmental quality
Immunizations
Access to health care
US National Institute of Health
Academy of Medical Royal Colleges UK
Februray 2015
Heart Disease
 40%
Reduction
 Two-thirds of the burden of cardiovascular diseases can be
attributed to the combination of diet and physical
inactivity.
 Physical activity has a very strong effect in reducing the
development of heart disease.17 Studies vary in quantifying
the reduction in risk of heart disease as “up to 50%”, or “20 35% lower risk” of cardiovascular disease and coronary
heart disease.
 People who change from doing minimal activity to
moderate activity have most to gain.
 Across a population, a move to active travel alone could
reduce heart disease by 10%.
Hypertension
 Exercising regularly reduces the risk of ever developing
hypertension by 52%.
Depresion
 Depression
 Lifetime risk 33%
 50% Obese Patients Depressed
 Risk Reduction General Population30%
There is a 20% to 33% lower risk of developing
depression, for adults participating in daily physical
activity
Dementia
 30%
The evidence is fairly consistent in quoting
reduced risks of developing dementia at “20-50%”.
20,35,77,78
Bowel Carcinoma
 45% Reduction
 Physical activity has a very strong effect in reducing
the occurrence of bowel cancer
 This is quantified at 30-50% lower risk.
 The 30 to 50% lower risk of colon cancer in men and
women across 19 international studies was related to
the beneficial effect of exercise on growth factors and
insulin resistance
Stroke
 30% Reduction
 Different reports quote exercise as reducing the risk of
stroke or of mortality from stroke by 20 - 40%.
Osteoarthritis
 50% Reduction
 Analysing several studies quantified the reduction in
risk of developing arthritis by undertaking moderate
exercise at between 22-83%.
Risk of diabetes
 physical activity is proven to reduce the risk of
developing type 2 diabetes by 50-80%.
Diabetes – Numbers to Treat for
Benefit
 6.4 Lifestyle including PA
 10 Medication but medication more side effects
First 15 Minutes Exercise a day
 416,175 people – average follow 8years
 3 years increase in Life expectancy
 15mins/day - 14% reduction all cause mortality
 Every extra 15 mins/day 4% extra < Mortality
 Chi Pang Wan et al Lancet Vol. 378-9798 1244-1253 Aug 2011
Exercise in non-diabetics
 Decreases insulin release
 Stimulates glucose transport into muscle
 Therefore, increase in insulin sensitivity
14
Exercise in non-diabetics
 Increases cortisol, catecholamines
 Increases glucagon
 Free fatty acids and liver glycogen to be mobilized for
energy
15
BENEFITS OF EXERCISE
 Increase insulin sensitivity
 Decreased triglyceride
 Improved functional






capacity
Enhanced sense of wellbeing
Reduced risk of CAD
Reduced risk of MI
Decreased ‘stickiness’ of
blood platelets
Reduced risk of High BP
Can reduce high BP






levels
Increased HDL levels
Decreased LDL levels
Improved HDL / LDL ratio
Decreased Body Fat
Decreased risk of
Osteoporosis
Decreased risk of Diabetic
associated complications
Fitness and Incident Metabolic Syndrome;
9007 Men and 1491 Women
Age-Adjusted Rate/1000
45
40
p<0.001,each
35
Middle
30
High
Low
25
20
15
10
5
0
Men
Women
LaMonte M et al. Circulation. 2005; 112:505-512
Fitness and Metabolic Syndrome;
11,833 Patients with 3-Day Diet Records
Odds of Metabolic Syndrome*
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
Thirds of CRF
Low
Moderate
High
Low intake
*Adjusted for confounders, including
macronutrient intake
High intake
Finley CE et al. JADA 2006; 106:673
Fitness and Incident Type 2 Diabetes;
8633 Healthy U.S. Men
Diabetes incidence/1000 men
6
5
4
3
2
1
0
Low
Mod
Cardiorespiratory Fitness
High
Wei M et al. Ann Int Med 1999
Fitness and Incident Type 2 Diabetes;
4747 Japanese Men;
Tokyo Gas Company
Relative risk adjusted for age and risk factors
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
I
II
III
IV
Level of Fitness
Sawada SS et al. Diab Care 2003; 26:2918
All-Cause Mortality by Fitness Groups
in 3,757 Men with Metabolic Syndrome
Odds Ratio
3
2.5
p for trend <0.001
2
1.5
1
0.5
0
Low
Moderate
High
Cardiorespiratory Fitness Groups
Katzmarzyk et al. Arch Int Med 2004; 164:1092
Risk of cardiovascular disease mortality by cardiorespiratory fitness and body mass index
categories, 2316 men with type 2 diabetes at baseline, 179 deaths.
Blair S N Br J Sports Med 2009;43:1-2
©2009 by BMJ Publishing Group Ltd and British Association of Sport and Exercise Medicine
Fitness and Cancer;
Mortality in 1744 Men with Diabetes
Relative risk of
Cancer Death *
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
p for trend =0.002
Low
Moderate
High
Cardiorespiratory
Fitness
*Adjusted for age and risk factors
Thompson AL et al. In progress
Lifestyle-related Risk Factors and Risk of
Future Nursing Home Admissions; 6462 Adults
RiskFactor
45-64years
HazardRatio(95%CI)
Smoking
1.56(1.23-1.99)
Inactivity
1.40(1.05-1.87)
BMI≥30.0
1.35(0.96-1.89)
HighBP
1.35(1.06-1.73)
HighCholesterol
1.14(0.89-1.44)
Diabetes
3.25(2.04-5.19)
Valiyeva E et al. Arch Int Med 2006; 166:985
Peripheral Neuropathy
 brisk 1-hour walk on a treadmill four times a week
slowed how quickly their nerve damage worsened
Indications for Exercise
 Longevity
 Quality of Life
 Socialization
 Weight control
 Disease prevention
 Disease management
 ….(I could go on)
Men
Women
No Physical Exercise During a 7-Day Period
40
37
33
Percent
30
27
20
26 27
21
21 21
18 17
10
0
14
11
1988
2002
18-34
1988
2002
35-54
1988
2002
55+
Slan Survey 1999
Percentage of respondents who reported no
exercise in an average week
Trend
towards inactivity being reversed?
Slan survey results reporting no
exercise
30
25
28
23
19
20
% reporting no
exercise
15
10
5
0
1998
2002
2007
Percentage of respondents who reported no exercise in an
average week, by age, gender and year
(1998, 2002 and
2007)
% reporting moderate &/or strenous
exercise 3 or more times per week for
at least 20 mins
41
41
40
40
39
38
38
37
36
1998
2002
2007
Physical Inactivity is a global priority
Global prevalence of
physical inactivity
31%
Irish prevalence of
physical inactivity
60%
As Presented by Prof. Fiona Bull, MBE at the NEHRF Expert Symposium in DCU on 19 th June, 2014
I think you’ll find it’s a bit more complicated than that
Ben Goldacre, www.Bad Science.net
Killing you softly and gently
CC www.TheNounProject.com
Components
Activity Thermogenesis
2000 Kcal/day
Thermal effect of food
1000 Kcal/day
Basal Metabolic Rate (BMR)
0 Kcal/day
More detailed!
2000 Kcal/day
Exercise
1000 Kcal/day
Non Exercise Activity
Thermogenesis
(NEAT)
0 Kcal/day
Some arguments in favour of NEAT
Circulation. 2007;116:1081-1093
Arterioscler Thromb Vasc Biol 2006;26;729-736
 20 females, BMI 32
 8 weeks of low energy diet
 500 kcal x 4w
 850 kcal x 4 w
 2 groups
 Exercise 3/w x 90 minutes
 No exercise
 Measured Average Daily and Sleeping Metabolic Rates
Am J Clin Nutr 1995;62:722-9.
Am J Clin Nutr 1995;62:722-9.
What we thought would happen
Exercise
Exercise
Non Exercise Activity
Thermogenesis
(NEAT)
Non Exercise Activity
Thermogenesis
(NEAT)
What really happened
Exercise
Exercise
Non Exercise Activity
Thermogenesis
(NEAT)
Non Exercise Activity
Thermogenesis
(NEAT)
Revising concepts is NEAT!
 Stable “Exercise” levels
 Obesity levels increase
 We do “more” with “less”(movement)
 NEAT decreases with inactivity.
 NEAT decrease may be the main factor in energy
overload
 In cohorts of people who do not exercise
 Increased rates of


DM
CAD
 Obesity
 CANNOT BE CAUSED BY ADDITIONAL “EXERCISE”
DEFICIENCY
Diabetes 56:2655–2667, 2007
Showing
 2 types of muscles, that react very differently to both
 Exercise
 Lack of movement (Sedentarism)
Arterioscler Thromb Vasc Biol. 2007;27:2650-2656
 Australian Diabetes, Obesity and Lifestyle (AusDiab
Study)
 173 patient, underwent OGTT
 Accelerometer based
Diabetes Care 30:1384–1389, 2007
 Same population
 Relationship of sedentarism and
 Waist circumference

3.1 cm difference
 Cluster of metabolic risk factors
Diabetes Care 31:369–371, 2008
 Cross sectional study of 1921 children,
 9-10 yold and 15-16 yolds
 Accelerometer based activity
 Self reported TV viewing
 Metabolic risk score
 TV viewing was NOT correlated with PA (r=0.013,
p=0.58)
PLoS Med 3(12): e488. doi:10.1371/journal.pmed.0030488
Obes Res. 2005;13:608–614
Med. Sci. Sports Exerc., Vol. 41, No. 5, pp. 998–1005, 2009
Non Exercisers
Even if you exercise, the effects are still there!
Exercisers
J Am Coll Cardiol 2011;57:292–9
Times that people spend sitting versus participating in
exercise based leisure time physical activity are different
classes of behavior with distinct determinants
AND INDEPENDENT RISKS FOR DISEASE
Different effects of sedentary behavior compared
to “exercise”
Metabolic and Mortality effects seen
Through age groups
Through ethnic groups
Newer objective data seems to support larger self
reported data
Diabetes 56:2655–2667, 2007
Diabetes Care 31:661–666, 2008
IDLE Breaks Study
 Baker IDI Heart & Diabetes Institute
 Effects of acute bout of sitting time in post prandial
Glc/Tg
 With and Without Breaks
Unpublished Data
Glucose
Insulin
Breaking news: New data
All are statistically significative!
Hot off the presses
 Treatment group burns 0.18 kcal/min more (17%
more) 300 calories/week
 In obese/overweight group, increases to 0.38 kcal/min
(32% more) 575 calories/week
Am J Public Health. 2011 Mar 18. [Epub ahead of print]
7 Investments that
work for physical activity
1. Whole-of-school’ programs
2. Transport policies and
systems that prioritise
walking, cycling and public
transport
3. Urban design regulations and
infrastructure that provides
for equitable and safe access
for recreational physical
activity, and recreational and
transport-related walking
and cycling across the life
course
4. Physical activity and NCD
prevention integrated into
primary health care systems
5. Public education, including mass
media to raise awareness and
change social norms on physical
activity
6. Community-wide programs
involving multiple settings and
sectors & that mobilize and
integrate community engagement
and resources
7. Sports systems and programs that
promote ‘sport for all’ and
encourage participation across
the life span
What are the new findings?
Outdoor walking groups have wide-ranging health benefits including reducing
blood pressure, body fat, total cholesterol and risk of depression.
Outdoor walking groups appear to be an acceptable intervention to
participants, with high levels of adherence and virtually no adverse effects.
Lifestyle Intervention:
Physical Activity Results
 74% of volunteers assigned to
intensive lifestyle achieved the
study goal of > 150 minutes of
activity per week at 24 weeks
The DPP Research Group, NEJM 346:393-403, 2002
Percent developing
diabetes
Incidence
of Diabetes
Placebo (n=1082)All
Metformin (n=1073, p<0.001 vs. Placebo)
Lifestyle (n=1079, p<0.001 vs. Met , p<0.001 vs. Plac )
Lifestyle
(n=1079,
,
Metformin
(n=1073,p<0.001
p<0.001vs.
vs. Metformin
Plac)
Placebo (n=1082) p<0.001 vs. Placebo)
Cumulative incidence (%)
40
30
participants
Risk reduction
31% by metformin
58% by lifestyle
20
10
0
0
1
2
Years from randomization
The DPP Research Group, NEJM 346:393-403, 2002
3
4
Intervention goals
 5% reduction in initial weight
 Exercise ≥30 min/day
 Decrease fat to <30% of caloric
intake
 Increase fibre to ≥15 g per 1000
kcal
 Decrease saturated fat to <10%
of caloric intake
Cumulative probability of
remaining free of diabetes
1.2
1.1
1.0
0.9
0.8
0.7
0.6
0.5
0.4
Intervention group
Control group
0
1
2 3 4 5
Study year
6
Tuomilehto et al. N Engl J Med 2001; 344: 1343–50
Cumulative probability of
remaining free of diabetes
1Year intensive intervention
1.2
1.1
4 years
58%
1.0
7 years
43%
0.9
0.8
13years
38%
0.7
0.6
5 Years Delay in onset DM
0.5
0.4
0
SLtDddddddddddudy year
Intervention group
Control group
2
3
4
5
6
1
13year follow up Jan 2013
Weight Change (kg)
Mean Weight Change
0
Placebo
-2
Metformin
-4
Lifestyle
-6
-8
0
1
2
Years from Randomization
The DPP Research Group, NEJM 346:393-403, 2002
3
4
Muscular Strengthening
 Exercise large muscle groups
 8-12 reps; should fatigue by last rep
 Rest 2-3 minutes between exercises
 1 set good, 2 sets better
 Rest day in between
Resistance training prevention
diabetes
 32002 men – 18 years
 150 minutes/week
 Resistance Training alone
 Aerobic Training alone
 Both


Health Professional follow up study
Arch Intern Med. 2012;172(17):1306-1312. doi:10.1001/archinternmed.2012.3138
34% reduction
52% reduction
59% reduction
Combined Training HbA1 DMtype2
Combined Training DM
 The prevalence of increases in hypoglycemic medications
were 39% in the control, 32% in the resistance training,
22% in the aerobic, and 18% in the combination training
groups with the Mantel-Haenszel test for linear association
being significant (P = .005). The prevalence of decreases in
hypoglycemic medications were 15% in the control, 22% in
the resistance training, 19% in the aerobic, and 26% in the
combination training groups (P = .20). The prevalence of
individuals who achieved the composite outcome of either
decreasing hypoglycemic medication or reducing HbA1c by
0.5% without increasing medications were 22% in the
control group, 26% in the resistance training, 29% in the
aerobic, and 41% in the combination training group
Conducting exercise stress testing before
walking is unnecessary. No evidence suggests
that it is routinely necessary as a CVD
diagnostic tool, and requiring it may create
barriers to participation.
ADA/ACSM November 2011
Pre-exercise evaluation
 Cardiac screening is controversial
 Decreased risk in DM of unexpected cardiac death
who exercise
 79% of perfusion abnormalities resolved 3 yrs with
medical therapy
 If exercise treadmill +, poor prognosis
 Don’t know result of interventions
Clin Sports Med 2009;28:379-92
Diabetes Care 2007;30:2892-8
76
Pre-exercise evaluation
 Asymptomatic Type II with + adenosine stress
compared with non screened
 No reduction in cardiac events
 High risk Type II revascularization vs aggressive
medical therapy
 No difference in long term mortality
JAMA 2009;301:1547-55
NEJM 2009;360:2503-15
77
Stress Testing Vigorous
 For exercise more vigorous than brisk walking or
exceeding the demands of everyday living, sedentary
and older diabetic individuals will likely benefit from
being assessed for conditions that might be associated
with risk of CVD, contraindicate certain activities, or
predispose to injuries, including severe peripheral
neuropathy, severe autonomic neuropathy, and
preproliferative or proliferative retinopathy
Who
to
do
stress
test?
 Low to moderate intensity, good control, not many
risk factors
 Start program
 Out of shape, starting program
 Start low to moderate intensity
 OR non-exercise imaging
Handbook of Exercise in Diabetes 2002
Clin Sports Med 2009;28:379-92
79
Who to do stress test?
 If moderate to high intensity exercise
 AND/OR ADA guideline risk factors
 Autonomic neuropathy
 PVD, retinopathy
 + EKG
 Stress test
 OR modify risk factors prior to exercise
Handbook of Exercise in Diabetes 2002
Clin Sports Med 2009;28:379-92
80
FACTORS WHICH PREVENT
EXERCISE
 READYNESS TO CHANGE
 Health concerns
 Family commitments
 Work commitments
 Transport difficulties
 Weather
 Cost
 Security concerns
Exercise Type II








Exercise reverses deficits in metabolism
Basal insulin
HbA1c
Basal glucose
Liver glucose production
Insulin stimulated glucose uptake
GLUT4 receptors
Insulin sensitivity
 Cholesterol, triglycerides
GSSI #90 2003;16(3)
82
Exercise Benefits
 20-30% reduction in HbA1c in Type II
 Decrease lipids
 Decrease blood pressure
 Weight loss and maintenance
 Reduce metabolic syndrome
 Reduce risk of CAD !!
83
Physical Activity and Mortality DM
 Total PA was associated with lower risk of CVD and total





mortality.
Compared with physically inactive persons, the lowest
mortality risk was observed in moderately active persons:
Hazard ratios were 0.62 (95% CI, 0.49-0.78) for total
mortality and 0.51 (95% CI, 0.32-0.81) for CVD mortality.
Leisure-time PA was associated with lower total mortality
risk, and walking was associated with lower CVD mortality
risk.
In the meta-analysis, the pooled random-effects hazard
ratio from 5 studies for high vs low total PA and all-cause
mortality was 0.60 (95% CI, 0.49-0.73).
Annals of Internal Medicine Online first August 2012
Borg perceived exertion scale

6 No exertion at all
7 Extremely light
8
9 Very light - (easy walking slowly at a comfortable pace)
10
11 Light
12
13 Somewhat hard (It is quite an effort; you feel tired but can continue)
14
15 Hard (heavy)
16
17 Very hard (very strenuous, and you are very fatigued)
18
19 Extremely hard (You can not continue for long at this pace)
20 Maximal exertion
Borg perceived exertion scale











Perceived Exertion Scale
Level 1: I'm watching TV and eating bon bons
Level 2: I'm comfortable and could maintain this pace all day long
Level 3: I'm still comfortable, but am breathing a bit harder
Level 4: I'm sweating a little, but feel good and can carry on a
conversation effortlessly
Level 5: I'm just above comfortable, am sweating more and can still talk
easily
Level 6: I can still talk, but am slightly breathless
Level 7: I can still talk, but I don't really want to. I'm sweating like a pig
Level 8: I can grunt in response to your questions and can only keep
this pace for a short time period
Level 9: I am probably going to die
Level 10: I am dead
METs
3.5-4
Moderate
Walking at a brisk pace (1 mi every 20 min)
Weight lifting, water aerobics
Golf, not carrying clubs
Leisurely canoeing or kayaking
Walking at a very brisk pace (1 mi every 17 to 18 min)
Climbing stairs
Dancing (moderately fast)
Bicycling <10 mph, leisurely
METs
4.5-6
 Moderately Vigorous Plus
 Slow swimming
 Golf, carrying clubs
 Walking at a very brisk pace (one mi every 15 min)
 Most doubles tennis
 Dancing (more rapid)
 Some exercise apparatuses
 Slow jogging (one mi every 13 to 14 min)
Vigorous Exercise
Hiking
Rowing, canoeing, kayaking vigorously
Dancing (vigorous)
Some exercise apparatuses
Bicycling 10 to 16 mph
Swimming laps moderately fast to fast
Aerobic calisthenics
Singles tennis, squash, racquetball
Jogging (1 mile every 12 min)
Skiing downhill or cross country
Why Resistance Training?
 Improves metabolism – proven reduction in Insulin
Resistance, incidence of D.M., additive effect to
aerobic exercise in prevention and treatment of IHD
 Improves muscle strength – less falls/#s
 Reduced Osteoporosis 1year increase BMD 1.3%
Controls loss 1.2%
 Arthritis – Reduced pain Improved function
Exercise that uses muscular strength to
move a weight or move against a resistive
load
In diabetes resistance exercise of the major
muscle groups on 2 non consecutive days in
the week is recommended
Resistance Training
 Resistance can be own body weight
 Press Up / Sit Up
 Light Weights – Dumb Bells
 Resistance bands
Progression
 Over time and as the person achieves 3 sets of 10-15
reps the weight can be increased, as this produces
impoved blood glucose effects
 As the weight increases the number of reps per set can
be reduced to 8-10