Exercise truly is medicine: Key
points for the general
practitioner
Ross Arena, PhD, PT, FAHA
Professor and Chief
Physical Therapy and Cardiology Division
University of New Mexico
Outline
• Why is aerobic fitness so important
• What we do as clinicians
“After adjustment for age
and other risk factors,
mortality was 13% lower
for every 1-MET increase
in exercise capacity.”
“The age-adjusted reduction was
graded and more pronounced in
whites than in blacks; each 1MET increase in exercise
capacity yielded 14% and a 19%
lower risk for blacks and whites,
respectively”
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
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30.0 ≤ BMI < 35.0
Church TS et al. Arch Int Med
2005; 165:2114
CRF and Risk of Incident
Hypertension, ACLS Women
• 4,884 healthy women
Risk of Developing Hypertension
examined at the Cooper
Clinic, 1970-1998
P for trend <0.01
• 157 women developed
hypertension during
average follow-up of 5
years
• Risk adjusted for age,
Fitness
exam year, alcohol intake,
Groups
smoking, BP, family
history of hypertension,
waist girth, glucose, &
triglycerides
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
Sui X et al. MSSE 2009; 41:742
Odds Ratio
p for trend=0.04
“Following a rigorous screening process, the 33 studies included
in the final analysis included more than 100,000 subjects, 6000
all cause mortality events and 4000 cardiovascular events. Each
one MET increase in aerobic capacity equated to 13 and 15%
decreases in all-cause mortality and cardiovascular events,
respectively.”
Actual Causes of Death
Tobacco
435
Inactivity/Poor diet
400
Alcohol
85
Microbial agents
43
Toxic substances
55
Motor vehicle crashes
Incidents involving firearms
29
Sexual behaviors
20
Illicit use of drugs
17
JAMA March 10, 2004
Leading Causes of Death, US
1. Tobacco, 18.1%
2. Poor diet and
Physical inactivity, 16.6%
3. Alcohol, 3.5%
43
0
100
200
300
400
19
500
Deaths per Year in U.S. (1,000s)
What can we do about it?
An initiative of:
Exercise As Medicine
• Tremendous health benefits are seen with even low levels
of exercise.
• Amount of exercise needed to benefit health is much lower
than amount needed for fitness
Regular physical activity at the correct intensity:
• Reduces the risk of heart disease by 40%.
• Lowers the risk of stroke by 27%.
• Reduces the incidence of diabetes by almost 50%.
• Reduces the incidence of high blood pressure, by almost 50%.
• Can reduce mortality and the risk of recurrent breast cancer by almost 50%.
• Can lower the risk of colon cancer by over 60%.
• Can reduce the risk of developing of Alzheimer’s disease by one-third.
• Can decrease depression as effectively as Prozac or behavioral therapy.
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U.S. Physical Activity Guidelines
150 minutes per week
of moderate-intensity
physical activity
• Choose your own schedule
• For example: 30 minutes of
moderate-intensity exercise, five
days per week OR three 10minute sessions per day,
five days per week
Age
No Chronic Conditions
Chronic Conditions
Children &
Adolescents
(6-17)
60 minutes or more of physical
activity every day (moderate*- or
vigorous**-intensity aerobic
physical activity).
Develop a physical activity
plan with your health care
professional. Avoid inactivity.
Refer to the Your
Prescription for Health
series.
Vigorous-intensity activity at least
3 days per week.
Muscle-strengthening and
bone-strengthening activity at
least 3 days per week.
Adults
(18-64)
150 minutes a week of moderateintensity, or 75 minutes a week of
vigorous-intensity aerobic
physical activity
Muscle-strengthening activities
that involve all major muscle
groups performed on 2 or more
days per week.
Develop a physical activity
plan with your health care
professional. Be as
physically active as possible.
Avoid
inactivity
Refer to the Your
Prescription for Health
series.
Older Adults
(65+)
Follow the adult guidelines, or be
as physically active as possible.
Avoid inactivity.
Exercises that maintain or
improve balance if at risk of
falling.
Develop activity plan with
health care professional.
Refer to the Your
Prescription for Health
series.
From the 2008 Physical Activity Guidelines for Americans
For more information on these guidelines, visit
www.acsm.org/physicalactivity.
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Summary
• Evidence is now overwhelming on the health burden of
physical inactivity.
• The benefits of exercise in the treatment and prevention of
chronic disease cannot be denied.
• We cannot continue to ignore this evidence when
formulating treatment plans for our patients.
• No patient should leave a doctor’s office without an
assessment of his/her physical activity and proper
prescription of an exercise program, or a referral to a
qualified fitness professional..
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Call to Action
•
•
•
•
•
•
Initiate a dialogue between
every physician and every
American.
Promote Exercise is Medicine™ in
organizations, workplaces and
communities.
Ensure that exercise is front and
center in the national discussion on
disease prevention, health and
wellness.
Large scale exercise initiative led by
health care providers:
– Every patient; Every visit; Every
treatment plan.
Physical activity should be recorded
as a vital sign.
Message should be the same from
every provider, regardless of
specialty.
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GOALS
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Program Goals
•
•
•
For physical activity to become a Vital Sign, with the Physician routinely
discussing it with each of their patients.
For the Physician to either prescribe appropriate physical activity to each
patient or to refer the patient to a qualified health and fitness professional
to get a physical activity prescription.
For the Public to begin to ask for and expect Physicians to discuss
physical activity during each office visit.
Exercise Is Medicine™ is a sustainable initiative to:
1. Influence national policy to obtain reimbursement for exercise counseling.
2. Influence medical health record companies to include exercise as a HEDIS
measure and health care systems to make exercise a vital sign.
3. Effect policy changes that support physical activity counseling and patient
referrals (to health fitness professionals) in clinical settings.
4. Produce an expectation among the public that health care providers should
and will ask about and prescribe exercise.
5. Encourage physicians and other health care providers to be physically active
themselves.
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PROGRAM SPECIFICS
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Action Guides
31
Public Action Guide
The Public Action Guide provides you with a
simple, fast and effective tool for using
exercise as a ‘medicine’ to help prevent or
manage many of the most common chronic
health conditions. It will also help you
approach your health care provider to
discuss physical activity as a part of a
disease prevention and management
strategy.
Guide Highlights
• Meeting the Guidelines and Starting an
Exercise Program
• My Exercise Plan
• Questions and Answers
• Exercise is Medicine™ Month
• Note to Health Care Providers
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Meeting the Guidelines
and Starting an
Exercise Program
Follow these guidelines to meet
the basic physical activity
recommendations after
consulting your health care
professional.
From the 2008 Federal Physical
Activity Guidelines for Americans.
For more information on these
guidelines, visit
www.acsm.org/physicalactivity.
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My Exercise Plan
The first step in meeting any
recommendation for how much
exercise to do is to simply get
started with an activity that will work
for you. These tools will help you in
assessing your health, figuring out
your barriers to exercise and
working through some of the
challenges to sticking with a
program.
• Pre-Exercise Health Assessment
• Barriers to Exercise Assessment
• Exercise Time Finder
• Cost/Benefit Analyzer
• … and more!
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Note to Health Care Providers
Share this resource with your health care provider during
your next annual checkup or scheduled visit.
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Health Care Providers’ Action Guide
The Health Care Providers’ Action Guide
provides physicians and other health care
providers with a simple, fast, and effective tool
for using physical activity, in the right
“dosage”, as a highly effective prescription for
the prevention, treatment, and management
of more than 40 of the most common chronic
health conditions encountered in primary
practice.
Guide Highlights
• Exercise Prescription and Referral Process
document
• Exercise Readiness and Prescription form
• Starting an Exercise Program patient handout
• Your Prescription for Health series
• Physician office flier
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Exercise Readiness &
Prescription
1. Determine patient’s current level
of activity and willingness to
exercise.
2. Determine if patient is fit to
exercise independently and what
type of fitness professional
would be best for referral.
3. Depending on patient’s stage of
change, take appropriate action
by referring patient to
educational material, writing
exercise prescription, and/or
referring patient to fitness
professional.
4. Refer patient to
www.ExerciseIsMedicine.org for
videos, fliers and resources.
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Health and Fitness Professionals’ Action Guide
The Health and Fitness Professionals’ Action Guide
provides health and fitness professionals with a
guide for how to work effectively with physicians and
other health care providers to use exercise and
physical activity, in the correct “dosage”, as a highly
effective patient care “prescription.”
Guide Highlights
• How to work with health care providers document
• Introductory letter to health care provider
• Health and Medical Questionnaire
• Fitness Assessment
• Informed Consent
• Cancellation Policy
• Starting an Exercise Program handout
• Your Prescription for Health series
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“Your Prescription for Health” series
• Provides information and advice on
exercising safely with health conditions.
• Physicians and fitness professionals
can recommend these to their
patients/clients during visits.
• Available for download online.
Exercising Following Coronary Artery Bypass Surgery
Exercising Following a Heart Attack
Exercising Following a Stroke
Exercising while Losing Weight
Exercising with Alzheimer's
Exercising with Anxiety and Depression
Exercising with Atrial Fibrillation
Exercising with Cancer
Exercising with Low Back Pain
Exercising with Peripheral Arterial Disease
Exercising with Visual Impairment
http://www.exerciseismedicine.org/YourPrescription.htm
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Public Service Announcements
The American College of
Sports Medicine (ACSM)
has partnered with the
United States' Office of the
Surgeon General to create
public service
announcements
(PSAs) promoting Exercise
is Medicine™. The PSAs
feature the acting surgeon
general, Rear Admiral
Steven K. Galson, M.D.,
M.P.H., and a message
encouraging physical
activity.
http://www.exerciseismedicine.org/PSA.htm
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Additional Resources
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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.
Assessing Physical Activity vs.
Physical Fitness
Conclusions and Need for
Future Research
• “Given the strong evidence linking
exercise test findings with risk in
asymptomatic subjects, we believe that
the next major priority is the design and
implementation of large-scale
randomized trials to determine whether
an exercise screening strategy leads to
an improvement in outcomes.”
Section on:
Questions?