Another (among many)
Reason to Exercise
William J. Evans
Donald W. Reynolds Institute on Aging
University of Arkansas for Medical
Sciences
University of Virginia
One of these people was the President of
the United States
University of Virginia
The
The sixth
sixth age
age shifts
shifts
Into
Into the
the lean
lean and
and slipper'd
slipper'd pantaloon,
pantaloon,
With
With spectacles
spectacles on
on nose
nose and
and pouch
pouch on
on side,
side,
His
His youthful
youthful hose,
hose, well
well sav'd,
sav'd, aa world
world too
too wide
wide
For
For his
his shrunk
shrunk shank
shank ;; and
and his
his big
big manly
manly voice,
voice,
Turning
Turning again
again toward
toward childish
childish treble,
treble, pipes
pipes
And
And whistles
whistles in
in his
his sound.
sound. Last
Last scene
scene of
of all,
all,
That
That ends
ends this
this strange
strange eventful
eventful history,
history,
Is
Is second
second childishness
childishness and
and mere
mere oblivion,
oblivion,
Sans
Sans teeth,
teeth, sans
sans eyes,
eyes, sans
sans taste,
taste, sans
sans everything
everything
As
As You
You Like
Like It,
It, Act
Act II,
II, Scene
Scene VII,
VII, lines
lines 157-166
157-166
University of Virginia
“Every day you get older. It’s the law”
Sundance Kid to Butch Cassidy
University of Virginia
University of Virginia
Prefontaine
90
84 ml•kg-1•min -1
80
Male Marathoners
70
Female Marathoners
60
50
Sedentary College Age
Men
Sedentary
Middle-Age Men40
Sedentary College-Age Women
30
20
10
University of Virginia
Ice Hockey
1972
1972 Silver
Silver Medal
Medal Olympic
Olympic 88 Crew
Crew Team
Team
80
70
VO2max
ml-1•kg-1•min-1
60
50
40
30
1970
1980
1990
Hagerman, et al, A 20-yr longitudinal study of Olympic oarsman,
Med Sci. Sports Exerc. 28:1150, 1996
University of Virginia
VO2max of sedentary 75 year old woman
compared to O2 cost of activities
VO2max
Run (6.5 mph)
Cleaning
Climb Stairs
Walk (2.5 mph)
0
0.25 0.5 0.75
1
1.25 1.5 1.75
2
2.25 2.5
Oxygen consumption (L/min)
University of Virginia
2100
0.24
1900
0.23
1700
0.22
1500
0.21
1300
0.20
1100
0.19
900
Basal Metabolic Rate
Creatinine Excretion
0.18
700
0.17
500
10
30
50
70
Urinary Creatinine
(mg/24 hrs)
Basal Oxygen Consumption
(L/min, STPD)
0.25
90
AGE (years)
Tzankoff and Norris, Effect of muscle mass decrease on age-related BMR
changes, J. Appl. Physiol., 43, 1001, 1977
University of Virginia
Sarcopenia
Age related loss of skeletal
muscle mass
University of Virginia
Prevalence of sarcopenia, Women
JAGS, 50:889-896, 2002 - NHANES III
100%
90%
80%
% 70%
60%
50%
40%
30%
20%
10%
0%
Class II Sarco.
Class I Sarco.
Normal
Class I: SMI within 1-2
SD of young adult
Class II: >2 SD of
young adult
1829
University of Virginia
3039
4049
5059
6069
7079
80+
Prevalence of sarcopenia, Men
JAGS, 50:889-896, 2002 - NHANES III
%
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
18-29 30-39 40-49 50-59 60-69 70-79
University of Virginia
80+
Sarcopenia
• Reduced protein reserves
• Decreased strength and functional
capacity
– Frailty, Falls
• Reduced aerobic capacity
• Reduced energy requirements
University of Virginia
Sarcopenia
Healthcare Costs
• Prevalence > 20% of people over 65
• $18.5 Billion in 2000
– 15% of total healthcare expenditures
• $860 excess for each sarcopenic man
and $933 for each sarcopenic woman
• 10% reduction in sarcopenia prevalence
would save $1.1 billion (in year 2000 $)
University of Virginia
% Fat Free Mass
%Fat
MEN
100
80
60
BODY
BODY
COMPOSITION
COMPOSITION
40
20
24.8
24.8
31.1
31.1
33.3
33.3
50-54
55-59
37.0
37.0
38.2
38.2
38.0
38.0
60-64
65-69
70-78
0
45-49
University of Virginia
WOMEN
% Fat Free Mass
% Fat
100
80
BODY
BODY
60
COMPOSITION
COMPOSITION
40
36.4
36.4
20
41.5
41.5
42.9
42.9
43.0
43.0
42.9
42.9
29.7
29.7
0
45-49
University of Virginia
50-54
55-59
60-64
65-69
70-78
Age-related changes in thigh
cross-sectional area
21 year old woman
63 year old woman
University of Virginia
% reporting functional limitation
BMI JAGS 50: 1802, 2002
70
Men
Women
60
50
40
%
30
20
10
0
< 18.5
18.5-24.9 25-29.9
30-34.9
Body Mass Index (kg/m2)
University of Virginia
> 35
Sarcopenic Obesity
Int J Obesity 28: 234, 2004
“Obesity was strongly associated with selfreported physical functional health,
equivalent to being 11 years older for men
and 16 y for women.”
“In clinical practice, BMI may be considered
as a simple to obtain marker of the risk of
functional impairment in the elderly.”
University of Virginia
Physical Activity and Obesity
• 59% of owners of obese dogs are obese
– (Modern Veterinary Practice)
• Men who spent more than 41 hours/wk
watching television were more than 4 times
as likely to be obese as men who watched
TV < 1hour/wk
– (Am J Public Health, 86, 1996)
University of Virginia
Things you will never hear in
Arkansas
•
•
•
•
•
•
We’re vegetarians.
I’ll have grapefruit instead of biscuits and gravy.
Give me a small bag of pork rinds.
Trim the fat off that steak
I’ll have the arugula and ridicchio salad.
Little Debbie snack cakes have too many fat
grams.
• Be sure my salad dressing is on the side.
University of Virginia
What Weight Loss Ads Should Say
University of Virginia
University of Virginia
University of Virginia
University of Virginia
Typical, ad libitum diet
35.2
15.
7
48.7
CHO
Fat
Prote in
Etha nol
University of Virginia
High carbohydrate, low fat diet
20
CHO
20
University of Virginia
60
Fa t
Protein
High carbohydrate low fat diet
Ad Libitum (Arch. Int. Med. 164: 210-217, 2004)
• When consumed ad libitum will produce
weight loss and improved oral glucose
tolerance in older subjects with impaired GT.
• Groups:
– Control (40% fat, 40% CHO, 20% Pro), no ex
– HICHO (20% fat, 60% CHO, 20% Pro), no ex
– HICHO, exercise: 3 days/wk, 75% max, 45
min/day
University of Virginia
Total energy intake (food weighback), kcal/d
3000
2500
kcal/d
2000
Control
1500
Lofat sed
Lofat ex
1000
500
0
Baseline
6 weeks
12 weeks
No differences from baseline
University of Virginia
6
High carbohydrate, ad
libitum diet with or
without aerobic exercise
compared to “typical”
American diet (40% kcal
from fat)
4
2
0
-2
#
-4
# p = 0.07
*p < 0.05
University of Virginia
-6
Mixed
Comp lex CHO
#
Sim ple CHO
*
HI-CHO/EX
Resting Metabolic Rate
14 00
13 00
12 00
11 00
10 00
Pre
Pos t
90 0
80 0
70 0
60 0
50 0
Control
Hi CHO
Hi CHOEX
No change in RMR after three months
University of Virginia
45
Pre
Pos t
*
Body Fat (%)
40
*
35
30
25
20
University of Virginia
Mixed
HI-CHO
HI-CHO/EX
* interaction (P < 0.05)
Glucose Disposal
Glucose Disposal
(mg/kg body mass/min)
5
*
* interaction (P < 0.05)
4
Pre
Post
*
3
2
1
0
Mixed
University of Virginia
HI-CHO
HICHO/EX
Low-fat dietary pattern and weight change over 7
years: the Women's Health Initiative Dietary
Modification Trial, JAMA 295: 39-49, 2006
• 48,835 postmenopausal women
– 29,294 decrease fat, increase fruit and grain intake (no kcal
restriction goal)
– 19,541 control group (diet-related information)
• Outcome
– Women in intervention group lost an average of 2.2 kg
(P<0.001) and maintained lower weight compared to control
for 7.5 years.
“Weight loss was greatest among women in either
group who decreased their % energy from fat”
University of Virginia
University of Virginia
Restaurant Hall of Shame (Center for Science in the Public Interest)
Each of these foods has more than 1,000 calories and one to four day's worth of saturated fat
Kcal
Fat g
Saturated Fat g
Cheese fries with ranch dressing
Movie theater popcorn with "butter”
topping (large)
Prime rib, untrimmed (16 oz.)
Fettuccine Alfredo
Stuffed potato skins with sour cream
Fudge brownie sundae
Cheesecake Factory Carrot Cake (1 slice)
Pizzeria Uno Chicago Classic (1/2 pizza)
3,010
217
91
1,640
1,280
1,500
1,260
1,130
1,560
1,500
126
94
97
95
57
84
74
73
52
48
48
30
23
30
Rice (8 cups)
1,600
1
0
Soy burger (30)
1,500
33
6
University of Virginia
University of Virginia
Aerobic Exercise and Aging: Does aging effect
the adaptation to aerobic exercise training?
Recruited older (age 6070 years) and young
(20-30) men and
women.
Frequency -- 3 d/wk
Intensity -- 70% VO2max
Duration -- 50 min/d
University of Virginia
60
Pre-Training
50
Post-Training
40
30
20
10
0
University of Virginia
OLD
Old (60-70)
30)
YOUNG
Young (20-
Older men and women experience a greater
relative increase in aerobic capacity as a
result of 12 weeks of aerobic exercise
training
YOUNG
(age 20-30)
OLD
(age 60-70)
0
10
20
% Change in VO2 max
Meredith, CN, et al. Peripheral effects of endurance training in young and old subjects. J
Appl Physiol 66(6):2844-2849, 1989.
University of Virginia
Pre-Training
*
Post-Training
2000
QO2
Muscle Oxidative Capacity
3000
1000
0
University of Virginia
OLD
(age 60-70)
YOUNG
(age 20-30)
Impaired Strength
Inability to lift 4.5 kg
70
60
50
%
Men
Women
40
30
20
10
0
55-65
University of Virginia
65-75
75-85
Jette, Am. J. Public Health, 71, 1981
Progressive Resistance Training
• Exercise during which a muscle contracts
just a few times against a heavy load or
with high tension. The load is
progressively increased with training.
• Distinct from endurance (aerobic exercise)
training during which muscles contract
against little or no resistance
University of Virginia
“If you would exercise, go in
search of the springs of life.
Think of a man swinging dumbbells for his health when those
springs of life are bubbling up in
far-off pastures unsought by
him”
Henry David Thoreau
University of Virginia
Number of repetitions
100
80
60
40
Strength training
intensity
20
0
0
20
40
60
80
100
% of 1 repetition maximum
University of Virginia
120
Resistance Exercise
• Subjects
– Previously sedentary men
– Age 60-72
• Exercise
– High intensity resistance
training
– Knee extensors and flexors
– 80% of 1RM, 3 sets of 8
repetitions,
– 1 RM measured weekly and
80% readjusted
– 12 weeks in duration
University of Virginia
50
*
40
PRE-TRAINING
MID-TRAINING
*
POST-TRAINING
30
1 RM
*
*
20
10
0
E XT EN SO RS
Extensors
F LE XO RS
Flexors
Frontera, WR, et al Strength conditioning in older men: Skeletal muscle
function and mass. J Appl Physiol 64:1038-1044, 1988.
University of Virginia
Muscle Cross
Sectional Area
Muscle
Fat
University of Virginia
*
*
Muscle Size
(cm2)
130
105
80
PRE
University of Virginia
MID
POST
Effects of 12 wks of resistance training
on energy needs
kJ/kgBW•d-1
200
150
RMR
Other EE
Strength Exercise
141±6*
125±3
100
50
0
Pre-Trai ning
University of Virginia
Post-Traini ng
Effect of Endurance Training on Total Energy
Expenditure in the Elderly
Pre-Training
Pre-Training
TEE
TEE == 2408
2408 kcal/day
kcal/day
During
During Training
Training
TEE
TEE == 2474
2474 kcal/day
kcal/day
14% 6%
25%
10%
10%
65%
from:
from: Goran
Goran &
& Poehlman
Poehlman
Am.
Am. J.
J. Physiol.
Physiol. 263:
263: E950,
E950, 1992
1992
University of Virginia
71%
RMR
TEM
EEPA
Training
Osteoporosis
• One in two women and one in eight men
aged 50 and over will have an osteoporosisrelated fracture in their lifetime.
• The estimated national direct expenditures
(hospitals and nursing homes) was $17
billion in 2001 -- $47 million per day.
– The cost is rising
University of Virginia
OSTEOPOROSIS
Risk
Risk of
of death
death for
for 50-year-old
white
white postmenopausal
postmenopausal women
women
Condition
Condition
Hip
Hip fracture
fracture
Breast
Breast cancer
cancer
Endometrial
Endometrial cancer
cancer
University of Virginia
Lifetime
Lifetime Risk
Risk (%)
(%)
2.8
2.8
2.8
2.8
0.7
0.7
SUBJECT
SUBJECT CHARACTERISTICS
CHARACTERISTICS
Control
Control (n=19)
(n=19)
Exercise
Exercise (n=20)
(n=20)
Age
Age (yrs)
(yrs)
57.3
57.3
61.1
61.1
Yrs
Yrs Post
Post Menopause
Menopause
9.8
9.8
11.6
11.6
Weight
Weight (kg)
(kg)
62.2
62.2
64.7
64.7
BMI
BMI (kg/m
(kg/m 22))
23.1
23.1
24.4
24.4
Nelson
Nelson et
et al,
al, Positive
Positive effects
effects of
of high
high intensity
intensity strength
strength training
training on
on multiple
multiple
risk
risk factors
factors for
for osteoporotic
osteoporotic fractures,
fractures, JAMA,
JAMA, 274:
274: 1909,
1909, 1994.
1994.
University of Virginia
Study Design
• Random assignment to resistance exercise
or sedentary control
• Control
– Not engage in resistance exercise or other
regular exercise program
– Maintain body weight
• Exercise
– 80% 1RM, 3 set of 8 reps, 2 d/wk
– Upper and lower body exercise
University of Virginia
Effects of 52 weeks of
of high
high intensity
intensity
resistance training
2
1
Change in
bone %
Femoral neck BMD
Lumbar BMD
Total body BMC
0
-1
-2
-3
Control
University of Virginia
Exercise
80
Control
Exercise
60
%
% change
change
in
in strength
strength
40
20
0
-20
LP
University of Virginia
KE
LPD
BE
AF
Muscle Mass Change
2
*
1.5
1
0.5
0
-0.5
-1
Control
University of Virginia
Exercise
Effects of strength training on balance:
Backward Tandem Walk Time
Baseline
Final
30
20
10
0
Control
University of Virginia
Exercise
Control
Exercise
2000
Activity
(kcal/week)
1000
0
Pre
Pre
Pre Training
Training
University of Virginia
Po
st
Post
Post Training
Training
Stress and Bone Density
• 3 - 4% increase in
bone density in 6
months
• 50 heel drops per
day
Bassey, E. J., Increase in femoral bone density in
young women following high-impact
exercise, Osteoporosis International 1994
4:72-75
University of Virginia
Death Rates According to Individual Performance
Tests—Age and Sex Adjusted
Deaths per 100 Person-Years
15
11.7
10
9.0
7.8
6.6
5
6.1
4.5
4.3
4.4
3.2
3.0
3.6
2.5
1.9
3.0
3.0
3
4
0
Test Category
0
1
2
3
4
Walk
% Distribution 5 23 25 26 22
University of Virginia
0
1
2
3
4
Chair Stands
22 19 20 20 19
0
1
2
Standing Balance
10 15 13 14 49
Death Rates According to Performance Test Summary
Score
Age and Sex Adjusted
15
Deaths per 100
Person–Years
12.3
10.0
10
7.2
6.4
5.6
6.2
5.7
5
4.2
3.6
2.7
2.5
2.0
1.3
0
0
1
2
3
4
5
6
7
8
9
10
Performance Test Summary Score
Guralnik JM, et al. J Gerontol Med Sci. 1994;49:M85-M94.
University of Virginia
11
12
Nursing Home Admission Rates According to
Performance Test Summary Score
Nursing Home Admissions
per 100 PersonŠYears
Age and Sex Adjusted
25
20
22.5
19.6
17.5
15
12.8
11.6
10.2
10
6.0
7.2
4.6
5
4.8
2.7
0.8
0.7
11
12
0
0
1
2
3
4
5
6
7
8
9
10
Performance Test Summary Score
Guralnik JM, et al. J Gerontol Med Sci. 1994;49:M85-M94.
University of Virginia
Kaplan-Meier survival estimates of dementia-free probability by performance-based
physician function (PPF) scores
Wang, L. et al. Arch Intern Med 2006;166:1115-1120.
Copyright restrictions
apply.
University
ofmayVirginia
Kaplan-Meier survival estimates for the probabilities of being dementia-free
Larson, E. B. et. al. Ann Intern Med 2006;144:73-81
University of Virginia
Fiatarone, M, E Marks, N Ryan, C Meredith, L Lipsitz,
and W Evans, High intensity strength training in
nonagenarians, JAMA, 263: 3029-3034, 1990
University of Virginia
SUBJECT CHARACTERISTICS
6 Women
4 Men
Age = 90.2 ± 1.1 (86-96 Years)
Pattern of Care:
Level 1 = 4 Subjects
Level 2 = 6 Subjects
80% had a history of falls
7 Subjects used an ambulatory assistive devise
4.5 ± 0.6 chronic diseases/subject
(JAMA, 263:3029-3034, 1990)
University of Virginia
Strength Changes in Nonagenarians
30
ONE RM (KG)
25
20
19.3
15
10
7.6
5
0
BASELINE
WEEK 8
Eight weeks of progressive resistance exercise training
resulted in a 200% increase in strength and a 10%
increase in muscle size in 90-year old nursing home
University of Virginia
residents
Exercise
Exercise training
training and
and nutritional
nutritional supplementation
supplementation for
for
physical
physical frailty
frailty in
in very
very elderly
elderly people
people
(N
(N Engl
Engl JJ Med
Med300:1769,
300:1769, 1994)
1994)
Age = 87.0 ± 0.6 (range
(range 72-98)
72-98)
69% were over the age of
of 85
85
83%
83% required
required an
an ambulatory
ambulatory assistive
assistive device
device
66%
66% had
had fallen
fallen at
at least
least once
once in
in previous
previous year
year
50%
50% arthritis;
arthritis; 44%
44% pulmonary
pulmonary disease;
disease; 44%
44% osteoporotic
osteoporotic
fracture;
fracture; 35%
35% hypertention;
hypertention; 24%
24% cancer;
cancer; 16%
16% diabetes;
diabetes; 13%
13%
myocardial
myocardial infarction
infarction
University of Virginia
Effects of Strength Training on Spontaneous Activity
in Frail, Institutionalized Men and Women
No Exercise
*
Exercise
-2500
University of Virginia
-1500
-500
500
1500
2500
3500
In very old nursing home
residents, 10 weeks of
progressive resistance
exercise training
•Increased walking
speed
•Increased stair climbing
ability
•Increased spontaneous
activity
•Decrease in depressive
symptoms
University of Virginia
Helen Zechmeister, Age 81, Weight
University
of Virginia
Lifter
Resistance Exercise:
• Increases Strength and Functional Capacity
• Increases Muscle Mass
• Enhances Nitrogen Balance (Retention of
Protein)
• Increases Levels of Physical Activity
• Improves Bone Health, Decreasing Risk of
Osteoporosis
• Increases Insulin Action, Decreasing Risk
of Diabetes
University of Virginia
RESISTANCE EXERCISE
CONCERNS
•• Arthritis
Arthritis:: Train
Train in
in range
range of
of motion
motion that
that is
is free
free of
of
pain
pain
•• Hypertension
Hypertension :: If
If blood
blood pressure
pressure is
is controlled
controlled
(individual
(individual is
is taking
taking medication),
medication), resistance
resistance
training
training is
is safe
safe
•• Heart
Heart Disease
Disease :: Resistance
Resistance training
training presents
presents aa
lower
lower demand
demand to
to the
the CV
CV system
system than
than does
does aerobic
aerobic
exercise.
exercise.
University of Virginia
A New Paradigm for Post-Cardiac Event
Resistance Exercise Guidelines
Adams, et al, Am. J. Cardiol. 97: 281-286, 2006
“ . . . changing the approach to resistance
exercise in cardiac rehabilitation will
accelerate patients’ return to their desired
levels of daily activity, improving patient
satisfaction and decreasing cardiac
rehabilitation program attrition.”
University of Virginia
Physician recommendations after surgery involving
sternotomy reported by patients in CR program at
Baylor Med Ctr
•
•
•
•
•
•
•
•
•
Lift >5 lbs for 6 wk
Lift anything for 1 month
Lift anything heavy for 8 wk
Lift >2 lbs
Lift or push anything
Lift more than a gallon of milk for
4 wk
Lift anything heavier than Dallas
phone book
Pull anything for 8 wks
Mow anymore
University of Virginia
•
•
•
•
•
•
•
•
Vacuum
Do anything but light cleaning for
7 wk
Mover funiture
Play tennis until after 6 wk
Push a grocery cart
Do anything strenuous
Do yard work for 8 wk
Do anything that would hurt you
Forces required to perform ADLs
Activity
•
•
•
•
•
•
•
•
•
•
•
•
•
Pushing open door to cardiac rehab
Pulling open door to leave CR
Pushing open door to leave building
Pulling door to Dr. office
Pushing door to leave Dr. office
Pushing IV pole w/drip bag across carpet
Opening freezer door
Pulling 1 gallon of milk from refrigerator
Lifting full laundry hamper
Flushing industrial toilet
Pushing with aid of arm to rise off bench
Opening car door
Lifting a Dallas phone book
University of Virginia
force in lbs
15.5
22
13
14.5
15.5
6.5
10.5
10.5
21.5
13.5
27.5
12.5
4.5
Massachusetts: Keep Moving Walking
Clubs
Peer driven program administered through MA
Executive Office of Elder Affairs
University of Virginia
Peer Exercise Program Promotes Independence
PEPPI
• Joint program between Penn State
University and PA Department of Aging
• Training of community-based peer leaders
• Stress practical aspects of how to begin and
maintain an exercise program for seniors
• Peer leaders establish exercise program in
community
University of Virginia
University of Virginia
PEPPI
• Currently 250 groups,
with a total of 5,452
participants.
• Programs in 67
counties in PA served
by 52 Area Agencies
on Aging
University of Virginia
PEPPI
Community-Based Exercise
• 82% can walk better
• 95% are better able to
get up from a seated
position
• 78% can climb stairs
more easily
• 84% have improved
balance
University of Virginia
PEPPI Participants
• 99% state that their health has
improved
• 87% state that they are more
independent
PA Department of Aging
University of Virginia
Woody Brown
Age 83
Surfer
University of Virginia
John Turner:
Age 67
Weight Lifter
University of Virginia
Aging is simply the accumulation of a
lifetime of inactivity and poor nutrition
University of Virginia
The Future of Nursing Homes
University of Virginia
Nobody really lives long
enough to die of old age.
We die from accidents, and
most of all, disuse
Walter
Walter Bortz,
Bortz, M.D.
M.D.
University of Virginia
Though I look old, yet I am strong
and lusty;
For in my youth I never did apply
Hot and rebellious liquors in my
blood
Nor did not with unbashful
forehead woo
The means of weakness and
debility;
Therefore my age is as a lusty
winter,
Frosty, but kindly. Let me go with
you;
I’ll do the service of a younger man
In all your business and
necessities
William
As you like it, Act II,
UniversityShakespeare,
of Virginia