Physical Activity (PA),
Exercise is Medicine
(EIM) and Obesity
Russ Hoff MS ATC LAT
• Only 4% of the nation’s total
healthcare bill each year is spent
on promoting healthy behaviors
Why?
LACK OF PATIENT ENGAGEMENT!
• The clinical care setting is not
well trained in behavioral
health, and they do not have
the skills to engage patients in
lifestyle changes!
“This study shows that high BMI, smoking,
and high fasting plasma glucose are the 3
most important risk factors in the United
States, and that although smoking is
decreasing, BMI and fasting plasma
glucose levels are steadily increasing.
These 2 risk factors pose unique challenges
in the United States given that unabated,
they have the potential to change the
health trajectory for individuals in many
states……..U.S residents need to do more to
maintain their weight or reduce it, when
needed, as well as access systems to
support their intentions.” p. 1467-68.
Mokdad, et al., JAMA. 2018; 319(14): 1444-1472.
Obesity is reflective of
•
Carotid remodeling
•
Increased central & brachial pressures
•
Reduced LV diastolic function
•
Decreased peak exercise LV contractility
102 men & women; 22-70 yrs; no CVD or DM
DeVallance. IJO. 2015
Obesity Defined (What)
Medical Complications of Obesity
Pulmonary disease
Idiopathic intracranial hypertension
abnormal function
obstructive sleep apnea
hypoventilation syndrome
Stroke
Cataracts
Nonalcoholic fatty liver disease
steatosis
steatohepatitis
cirrhosis
•
•
•
Adverse HE outcomes
$ Medical system
Difficult to reverse
Coronary heart disease
Diabetes
Dyslipidemia
Hypertension
Gall bladder disease
Gynecologic abnormalities
Cancer
abnormal menses
infertility
polycystic ovarian syndrome
breast, uterus, cervix
colon, esophagus, pancreas
kidney, prostate
Osteoarthritis
Skin
Gout
Phlebitis
venous stasis
BMI & All Cause Mortality
1,32
1,40
1,20
Hazard Ratio
1,00
Why is it a problem?
1,00
0,92
1,00
0,80
0,60
0,40
0,20
0,00
BMI
Flegal. JAMA.2013
Adult Obesity Prevalence
BMI 2011-2012 United States NHANES
III
18%
33.9%
Over-Wgt
35.1%
Obese
31%
Normal or
Under - Wgt
Classification
Underweight
Normal
Overweight
Obese I
Obese II
Obese III
Kg/m2
< 18.5
18.5 – 24.2
25.0 – 29.9
30.0 – 34.9
35.0 – 39.9
> 40
Whom is
it impacting?
II
23%
I
59%
Ogden. JAMA. 2014
Today’s size 0 dress is larger than a size 8 in 1958
The average female weight today = average male weight in 1960
Epidemic !!!!
Epidemic !!!!
Medical experts warn obesity is a disease that must be treated
Updated 26 Aug 2013
A Sydney man who successfully sued his GP for failing to treat his obesity,
lost a bid to be heard in the High Court after the GP had his original
judgement overturned.
"It's a wake-up call to society and also the medical
profession, and the case is really about changing people's
perceptions about obesity," he said.
"Changing the way doctors think. Changing the way the
average person in the street thinks about obesity.
"It's a disease. You need to take it seriously and do
something proactive about it."
London Bus Study - 1953
1.9/1,000
Surgeon General’s Report - 1996
2.7/1,000
“The conductors had less coronary heart
disease than the drivers, and the disease
seemed to be appearing in them at a later
age.”
Jeremy N. Morris
Epidemiologist
“This landmark review of the research on
physical activity and health - the most
comprehensive ever … It is a work of real
significance, on par with the Surgeon
General's historic first report on smoking
and health published in 1964.”
Donna E. Shalala
U.S. Secretary of HHS
15
Professor in the Department
of Human Evolutionary
Biology at Harvard University.
“Dose response curves show
that just 150 minutes of
exercise a week — only 21
minutes a day — lowers
mortality rates by about 50
percent,” Lieberman said.
“Knowing that, I think, can
help people feel better about
doing just a little exercise
instead of none.”
How to fix it
“ … a primary source of information for policy
makers, physical educators, health providers,
and the public on the amount, types, and
intensity of physical activity needed to achieve
many health benefits for Americans across the
life span.”
Michael O. Leavitt,
US Secretary of HHS, 2008
• 2018 Guidelines – Fall 2018 release ?
• March 15, 2017 – Legislation would require
HHS to publish:
• Every 10 yrs - “Physical Activity
Recommendations for Americans”
• At 5-yr point, “Best practices and
continuing issues in the physical activity
area”
17
Br J Sports Med 2014; 48: 169-170
Br J Sports Med January 2009 43(1)
Mann & Rosenzweig. Can exercise teach us how to treat heart disease? Circulation. 2012;126:2625-2635
Sharma S et al. Eur Heart J 2015;36:1445-1452
FIGURE
Which US States Pose the Greatest Threats to Military
Readiness and Public Health? Public Health Policy Implications
for a Cross-sectional Investigation of Cardiorespiratory Fitness,
Body Mass Index, and Injuries Among US Army Recruits
Bornstein, Daniel B.; Grieve, George L.; Clennin, Morgan N.;
McLain, Alexander C.; Whitsel, Laurie P.; Beets, Michael W.;
Hauret, Keith G.; Jones, Bruce H.; Sarzynski, Mark A.
Journal of Public Health Management and Practice25(1):36-44,
January/February 2019.
doi: 10.1097/PHH.0000000000000778
States Ranked by Quartiles of Cardiorespiratory Fitness of
Males (A) and Female (B) US Army Recruits and TrainingRelated Injury Incidence of Male (C) and Female (D) US
Army Recruits Entering Basic Training From 2010 to 2013
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
24
Circulation, 2013;128:2259-2279
Physical activity assessment should be considered a vital health measure that is regularly tracked over time,
along with other major modifiable risk factors (DM, HTN, HLP, Smoking, Obesity and etc. The present scientific
statement provides a guide to allow professionals to make a meaningful and specific PA assessment
Circulation. 2016;134:00-00
Small increases CRF (1-2 METs) are associated with a considerable (10% -30%) reduction in CV event rates. Efforts to
improve CRF should become a standard part of clinical encounters – an accepted vital sign. CRF is as strong a predictor
of mortality as established risk factors such as smoking, hypertension, hyperlipidemia and Type 2 Diabetes.
Lobelo, et al., Circulation. 2018;137:00-00
Med Sci Sport Exerc 44(11):2071-2076, Nov 2012
• PA as a Vital Sign
• Electronic Medical Records
"Healing the Present...Teaching the Future"
29
“Health professionals should personally engage in an
active lifestyle to familiarize themselves with the issues
involved in maintaining lifelong physical activity and to set
a positive example for patients and the public.”
AHA Scientific Statement. Exercise and Physical Activity
in the Prevention and Treatment of Atherosclerotic
Cardiovascular Disease. Circulation. 2003; 107:31093116
It is difficult to suggest physical activity, prescribe
an exercise program, recommend dietary
modifications, or encourage other lifestyle
changes conducive to health if one does not feel
good about their own such behaviors.
30
Chronic Disease
• 75% of our health care spending is on people
with chronic conditions
• 7 out of 10 deaths among Americans are from
chronic diseases
• Almost 1 out of 2 adults in 2005 had at least
one chronic illness
Health Disparities
• Chronic disease and mortality are widespread
among members of racial and ethnic minority
populations
• Heart disease rates are higher among African
Americans than whites
• Diabetes is substantially higher among American
Indians and Alaska natives than whites
Relative Risks* of All-Cause Mortality among Harvard Alumni,
1977-1992, according to Physical Activity and Weight in 1977
Sedentary = < 1,000 Kcals/wk
1,00
Overweight = > 25 kg/m2
0,95
0,90
0,85
0,80
0,75
0,70
0,65
0,60
Sedentary
Overweight
Sedentary
Lean
Active
Overweight
*adjusted for age, smoking, alcohol, fm hx
Active Lean
Lee. Am J Epi 2000