Exercise Is Medicine—Putting
Science in to Clinical Practice
Preventive Medicine 2010
Arlington, VA
February 18, 2010
Steven N. Blair
Departments of Exercise Science &
Epidemiology/Biostatistics
University of South Carolina
Disclosures

Medical/Scientific Advisory Boards
• Jenny Craig, Inc
• Alere
• Technogym

Research Funding
•
•
•
•
NIH
Body Media
Coca Cola
Swimming Pool Foundation
Exercise Is Medicine
www.exerciseismedicine.org
Exercise Is Medicine
World Congress
Baltimore, MD
June 1-3, 2010
Dr. & Mrs.
Jerry Morris
with Brad Pitt
Aerobics Center
Longitudinal Study
Design of the ACLS
1970 More than 80,000 patients 2005
Cooper Clinic examinations--including
history and physical exam, clinical tests,
body composition, EBT, and CRF
Mortality surveillance to 2003
More than 4000 deaths
1982 ‘86 ‘90 ‘95 ’99 ‘04
Mail-back surveys for case finding and
monitoring habits and other characteristics
Age adj death rate/10,000 PY
All-Cause Death Rates by CRF
Categories—3120 Women and
10 224 Men—ACLS
70
Women
Men
60
50
40
30
20
10
0
Low
Moderate
High
Blair SN. JAMA 1989
Deaths/10,000 MY*
Cardiorespiratory Fitness, Risk
Factors and All-Cause Mortality, Men,
ACLS
60
50
40
# of risk factors
30
2 or 3
20
10
0
1
0
Risk Factors
High
Mod
Low
current smoking
Cardiorespiratory Fitness Groups
SBP >140 mmHg
*Adjusted for age, exam year, and other risk factors Chol >240 mg/dl
Blair SN et al. JAMA 1996; 276:205-10
CRF and Risk of Incident
Hypertension, ACLS Women



4,884 healthy women
examined at the Cooper
Clinic, 1970-1998
157 women developed
hypertension during
average follow-up of 5
years
Risk adjusted for age,
exam year, alcohol intake,
smoking, BP, family
history of hypertension,
waist girth, glucose, &
triglycerides
Risk of Developing Hypertension
P for trend <0.01
Fitness
Groups
Barlow CE et al. Am J Epidemiol 2006; 163:142-50
CRF and Digestive System
Cancer Mortality
38,801 men, ages 20-88
years
•283 digestive system
cancer deaths in 17 years
of follow-up
CRF was inversely
associated with death after
adjustment for age,
examination year, body
mass index, smoking,
drinking, family history of
cancer, personal history of
diabetes
•Fit men had lower risk of
colon, colorectal, and liver
cancer deaths
•
High Fit
Moderately Fit
Low Fit
Peel JB et al. Cancer Epidemiol Biomarkers Prev 2009; 18:1111
CRF and Breast
Cancer Mortality
14,551 women, ages 20-83
years
•Completed exam 1970-2001
•Followed for breast cancer
mortality to 12/31/2003
•68 breast cancer deaths in
average follow-up of 16 years
•Odds ration adjusted for age,
BMI, smoking, alcohol intake,
abnormal ECT, health status,
family history, & hormone use
Odds Ratio
•
Sui X et al. MSSE 2009; 41:742
p for trend=0.04
Activity, Fitness, and
Mortality in Older Adults
Cardiorespiratory Fitness and All-Cause
Mortality, Women and Men ≥60 Years of Age




4060 women and men
≤60 years
989 died during ~14
years of follow-up
~25% were women
Death rates adjusted
for age, sex, and
exam year
All-Cause death rates/1,000 PY
45
40
35
Low
Moderate
High
30
25
20
15
10
5
0
60-69
70-79
80+
Age Groups
Sui M et al. JAGS 2007.
Cardiorespiratory Fitness and
Risk of Dementia, ACLS



59,960 women and men
Followed for 16.9 years
after clinic exam
4,108 individuals died
• 161 with dementia listed on
the death certificate

Hazard ratio adjusted for
age, sex, exam yr, BMI,
smoking, alcohol,
abnormal ECG, history of
hypertension, diabetes,
abnormal lipids, and health
status
Hazard Ratio
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
Fitness Categories
Lui R et al. Research in progress
Multivariate + % Body Fat adjusted HR of
All-Cause Mortality by Fitness Groups,
ACLS, 2603 Adults 60+
Adjusted HR
1.2
p for trend <0.001
106 deaths
1
0.8
98 deaths
95 deaths
0.6
90 deaths
61 deaths
0.4
0.2
0
Q1
Q2
Q3
Q4
Q5
Cardiorespiratory Fitness
*Adjusted for age, exam year, smoking, abnormal exercise ECG,
baseline health conditions, and percent body fat
Sui M et al. JAMA 2007; 298:2507-16
Cardiorespiratory Fitness and
Health Outcomes in Various
Population Subgroups
Such as People Who Are
Overweight or Obese
CVD Mortality Risk* by Fitness and BMI Categories,
2316 Men with Diabetes, 179 CVD Deaths
10
8
7
6
p for trend <0.0001
p for trend <0.002
p for trend <0.0001
5
Reference
Risk of CVD Mortality
9
4
3
2
1
18.5 < BMI <25.0
25.0 ≤ BMI <30.0
*Adj for age and examination year
ig
h
w
M
od
/H
Lo
h
Hi
g
M
od
Lo
er
at
e
w
h
Hi
g
M
od
Lo
er
at
e
w
0
30.0 ≤ BMI < 35.0
Church TS et al. Arch Int Med
2005; 165:2114
Joint Associations of CRF and % Body Fat
with All-cause Mortality, ACLS Adults 60+
Death rate/1,000 person-years
40
Normal
Obese
30
20
10
0
Fit
Deaths
151 190
Unfit
29
72
Rates adjusted for age, sex and exam year
Sui M et al. JAMA 2007; 298:2507-16
Muscular Strength and
Mortality
Strength, Adiposity, and Cancer Mortality
8,677 men, 20-82 years
•18.8 years of follow-up,
211 cancer deaths
•Muscular strength
assessed by 1-RM bench
press and leg press
•Significant trend across
strength categories
remained after further
adjustment for BMI, %
body fat, waist
circumference, and
cardiorespiratory fitness
Odds of Cancer Death*
Ruiz J et al. Cancer Epidemiol
Biomarkers Prev 2009; 18:1468
*Adj for age, exam yr, smoking
alcohol intake, and health status
•
P for trend=0.003
Thirds of Strength
Yes, But Those Are
Observational Studies, and
We Require Randomized
Clinical Trial Evidence
Change in
Physical Health
12
10.35
10
8.56
SPH
8
7.35
6
4
3.05
2
0
Control
72 minutes
136 minutes
192 minutes
Study Groups
Martin CK et al. Arch Int Med 2009; 169:269-78
Change in
Mental Health
14
11.86
12
SMH
10
8.41
8.55
72 minutes
136 minutes
8
6
4
3.32
2
0
Control
192 minutes
Study Groups
Martin CK et al. Arch Int Med 2009; 169:269-78
Change in
Energy
16
14.42
14
12.25
12
11.58
VT
10
8
6
5.21
4
2
0
Control
72 minutes
136 minutes
192 minutes
Study Groups
Martin CK et al. Arch Int Med 2009; 169:269-78
Reduction in Risk of Developing
Diabetes in Comparison with Controls,
DPP
Risk reduction (%)
100
80
60
*Moderate intensity exercise of 150
min/week; low calorie, low fat diet
58%
40
31%
20
0
Lifestyle Intervention*
DPP Research Group. NEJM 2002; 346:393-403
Metformin
Cost Effectiveness of Diabetes
Prevention-DPP


DPP Res Group. Diab Care 2003; 26:2518
Lifestyle
Metformin
Per QALY
Gained
$100,000
$90,000
$80,000
$70,000
$60,000
$50,000
$40,000
$30,000
$20,000
$10,000
$0
Per Case
Delayed/Prev
The lifestyle and
metformin groups
cost $2,250 more/year
than placebo
As implemented in
the DPP and from a
societal perspective,
lifestyle was more
cost effective than
metformin
Summary
Gain in Longevity for a 45Year Old Male
Years of added life
8.7 years
10
8
5.8 years
6
4
2
0
Low vs Moderate
Low vs High
Comparison of Low, Moderate, and High Fitness Levels
Health Care Overview


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Medical care costs in the U.S are
~17% of GNP, by far the highest in
the world
By traditional public health markers
such as longevity, chronic disease
rates, infant mortality, etc; the U.S.
ranks far behind many other
countries
Most health problems are the result
of unhealthy lifestyles
We must be more aggressive in
integrating lifestyle interventions
into medical practice and public
health programs
Behavioral Approaches to
Physical Activity Interventions

Theoretical foundations
• Social Learning Theory
• Stages of Change Model
• Environmental/Ecological Model

Methods
•
•
•
•
•
•
•
Problem solving
Self-monitoring
Goal setting
Social support
Cognitive restructuring
Incremental changes
Manipulating the environment
Lessons Learned from Physical
Activity Intervention Studies


Individuals who use cognitive and
behavioral strategies are more likely
to be active at 24 months than
individuals who do not use these
strategies
Approximately 25-30% of initially
sedentary persons who participate in
Active Living will be meeting
consensus public health guidelines
for physical activity at 24 months
How to Achieve Lifestyle Change

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Counseling by a PhD level
behavioral psychologist
Counseling by B.A. level health
educators
Counseling by mail and
telephone
Counseling by electronic
communications
Lifestyle Interventions
Integrated with Electronic
Health Records—
Kaiser Permanente
Exercise as a Vital Sign
Kaiser Permanente
Within the Visit Navigator, you will now see the “Exercise Vitals”
section immediately following the “Vitals” section.
Exercise as a Vital Sign
Kaiser Permanente
When you click on the “Exercise Vitals” the section opens up to display the
two exercise intake questions that can be completed in a quick manner.
The date and time this data was captured will also be noted/stored.
Telehealth and Weight Change
87 participants (73
women & 14 men)
•Mean age 50 years
•Treatment groups (Quasiexperimental design)
•
Kg change at 6 mo
p <0.05
•Traditional class
•Telehealth—interaction
with RD via web and
email
•Control
No difference in
satisfaction between
traditional and telehealth
•Telehealth more
convenient than
traditional (p<0.0001)
•
Traditional
Control
Telehealth
Haugen HA et al. Obes 2007;
15:3067-77
Promoting PA via PDA



37 healthy, inactive adults, ≥50 years
of age
8-week RCT
PDA intervention (93% had not used
PDAs)
• Questions about amount and type of PA
• Alerted at 2 PM and 9 PM to complete PA
assessment
• Gave motivational and behavioral tips

Controls—standard written materials
King AC et al. Am J Prev Med 2007; 34:138-42
Promoting PA via PDA


Intervention participants completed
68% of the 112 PDA entries available
After adjusting for baseline differences
• PDA group reported 310.6 minutes of
moderate to vigorous PA/week
• Control group reported 125.5
minutes/week
• p=0.048 for group comparison

78.6% of PDA group reported enjoying
using the device
King AC et al. Am J Prev Med 2007; 34:138-42
Summary



Unhealthful lifestyles are the major
cause of chronic disease morbidity
and mortality
Lifestyle interventions have
demonstrated efficacy and
effectiveness in a variety of
populations
Our challenge now is to develop
translational interventions, using
modern technology, to reach large
numbers of individuals at a low cost.
Thank you