EXERCISE IN
PREVENTION
AND
MANAGEMENT
OF DISEASE
Dr Louis Holtzhausen
Division Sport and Exercise Medicine
SPORT AND EXERCISE MEDICINE
• Medical care of the
athletic population
SPORT AND EXERCISE MEDICINE
• Rehabilitation of chronic
diseases of lifestyle
– Cardiac
– Pulmonary
– Metabolic
SPORT AND EXERCISE MEDICINE
• Prevention of chronic
diseases of lifestyle
– Cardiac
– Pulmonary
– Metabolic
– Other
• Improving quality of life
AIMS
• Discuss primary and secondary prevention of disease
• Describe the burden of non-communicable disease and the role of
prevention in health care
• Show that the monitoring and prescription of
exercise by doctors can make a major
contribution to:
– Relieving the burden of health care in South Africa and
elsewhere
– Improving the health and quality of life of people
– Improving the prognosis of our patients/cardiac patients
PREVENTION OF DISEASE
• Primary prevention
– Health promotion
• Secondary prevention
– Risk factor modification
• Tertiary prevention
– Rehabilitation of disease
BURDEN OF DISEASE
• The double burden of
disease
– Infectious disease and
famine
– Non-communicable
disease
DISEASE BURDEN ATTRIBUTABLE TO 24 GLOBAL RISK
FACTORS BY INCOME AND WHO REGION, 2004
The South African scenario
No
Risk factor
%
deaths
No Disease/condition
%
deaths
1
Unsafe sex/STIs
26.3
1
HIV and AIDS
25.5
2
Hypertension
9.0
2
Ischaemic heart disease
6.6
3
Tobacco smoking
8.5
3
Stroke
6.5
4
Alcohol harm
7.1
4
TB
5.5
5
High BMI
7.0
5
Violence injury
5.3
6
Interpersonal violence
6.7
6
Lower resp infections
4.4
7
High cholesterol
4.6
7
Hypertensive disease
3.2
8
Diabetes
4.3
8
Diarrhoeal disease
3.1
9
Physical inactivity
3.3
9
Road traffic injury
3.1
10
Low fruit/veg intake
3.2
10
Diabetes mellitus
2.6
Norman et al, 2007 in MRC chronic disease report 1995-2005
Modifiable by exercise
No
Risk factor
%
deaths
No Disease/condition
%
deaths
1
Unsafe sex/STIs
26.3
1
HIV and AIDS
25.5
2
Hypertension
9.0
2
Ischaemic heart disease
6.6
3
Tobacco smoking
8.5
3
Stroke
6.5
4
Alcohol harm
7.1
4
TB
5.5
5
High BMI
7.0
5
Violence injury
5.3
6
Interpersonal violence
6.7
6
Lower resp infections
4.4
7
High cholesterol
4.6
7
Hypertensive disease
3.2
8
Diabetes
4.3
8
Diarrhoeal disease
3.1
9
Physical inactivity
3.3
9
Road traffic injury
3.1
10
Low fruit/veg intake
3.2
10
Diabetes mellitus
2.6
Norman et al, 2007 in MRC disease report
VIDEO CLIP 1
•
Question 1:
•
Which group of factors that determine a person’s health and longevity can
be managed best by medical professionals?
VIDEO CLIP 1
•
Question 2:
•
•
What are the current leading causes of death in the world?
In South Africa?
VIDEO CLIP 1
•
Question 3:
•
What is the current most dangerous non-communicable disease epidemic in
the world?
VIDEO CLIP 1
•
Question 4:
•
What is the most important risk factor for cardiac disease – obesity or
inactivity?
VIDEO CLIP 1
•
Question 5:
•
Name 7 conditions that can be modified effectively by exercise.
EXERCISE IS MEDICINE®
• Dr Robert Sallis, MD
• American College of Sports Medicine (ACSM)
VIDEO CLIP 1
•
Question 1:
•
Which group of factors that determine a person’s health and longevity can
be managed best by medical professionals?
VIDEO CLIP 1
•
Question 2:
•
•
What are the current leading causes of death in the world?
In South Africa?
VIDEO CLIP 1
•
Question 3:
•
What is the current most dangerous non-communicable disease epidemic in
the world?
VIDEO CLIP 1
•
Question 4:
•
What is the most important risk factor for cardiac disease – obesity or
inactivity?
VIDEO CLIP 1
•
Question 5:
•
Is it dangerous for patients to exercise after angioplasty?
VIDEO CLIP 2
•
Question 6:
•
Name 7 conditions that can be modified effectively by exercise.
VIDEO CLIP 2
•
Question 7:
•
How much more does it cost to treat inactive patients than active ones in
the USA?
VIDEO CLIP 2
•
Question 8 :
•
Why is a dog really man’s best friend?
VIDEO CLIP 2
•
Question 9:
•
What are the three most effective interventions to treat coronary artery
disease?
RELATIVE RISK FROM PHYSICAL
INACTIVITY IS SIMILAR TO THE
RISK ASSOCIATED WITH THE 3
OTHER MAJOR RISK FACTORS#
FOR CAD
#Smoking,
hypertension,
hypercholesterolaemia
CONCLUSION
• Exercise is a powerful tool
in the prevention and
management of noncommunicable disease
• Exercise is more effective
in prevention and
treatment of many chronic
diseases than medication
or other modalities
• Exercise should be
monitored and prescribed
by all doctors
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Table 1: Biological mechanisms by which exercise may contribute to the primary or secondary prevention of
CAD12.
1. MAINTAIN OR INCREASE MYOCARDIAL OXYGEN SUPPLY
Delay progression of coronary atherosclerosis (possible)
–
Improve lipoprotein profile (increase HDL:LDL ratio) (probable)
–
Improve carbohydrate metabolism (increase insulin efficiency) (probable)
–
Decrease platelet aggregation and increase fibrinolysis (probable)
–
Decrease adiposity (usual)
Increase coronary collateral vascularization (unlikely)
Increase epicardial artery diameter (possible)
Increase coronary blood flow (myocardial perfusion) or distribution (possible)
2. DECREASE MYOCARDIAL WORK AND OXYGEN DEMAND
Decrease resting heart rate and submaximal exercise heart rate (usual)
Decrease systolic and mean systemic arterial blood pressure during submaximal exercise (usual) and at rest (possible)
Decrease cardiac output at submaximal exercise (probable)
Decrease circulating plasma catecholamine levels (decrease sympathetic tone) at rest (probable) and at submaximal
exercise (usual)
3. INCREASE MYOCARDIAL FUNCTION
Increase stroke volume at rest and submaximal and maximal exercise (likely)
Increase ejection fraction at rest and during exercise (likely)
Increase intrinsic myocardial contractility (possible)
Increase myocardial function resulting from decreased afterload (probable)
Increase myocardial hypertrophy (probable) #
4. INCREASE ELECTRICAL STABILITY OF MYOCARDIUM
Decrease regional inchaemia or ischaemia at submaximal exercise (possible)
Decrease catecholamines in myocardium at rest (possible) and atsubmaximal exercise (probable)
Increase ventricular fibrillation threshold attributable to reduction of c-AMP (possible)
Note: Expression of likelihood that effect will occur in an individual participating in endurance training program for
16 weeks or longer at 65% to 80% of functional capacity for 25 minutes or longer per session (300kcal) for three or
more sessions per week ranges from unlikely, possible, probable, to usual.
#: May not reduce CAD risk.
MAIN PHYSIOLOGICAL CARDIAC ADAPTATIONS
• Reduction in heart
rate and blood
pressure during
submaximal exercise
• Increased maximum
cardiac output and
oxygen consumption
(VO2max) during
maximal exercise
PERIPHERAL ADAPTATIONS PERSPECTIVE
• Adaptations in CVS function are specific to
exercise of trained muscles
• Implication: the major adaptations in CVS
function occur in the periphery:
– Increased capillarisation
– Increased mitochondrial content
– Enhanced contractility
EXERCISE CAN BE OF
VALUE TO PERSONS
WITH IMPAIRED
CARDIAC FUNCTION
EXERCISE PRESCRIPTION FOR CHRONIC DISEASE
• Cardiorespiratory fitness
• Muscle strength and
endurance
• Flexibility
FITT PRINCIPLE
•
•
•
•
Frequency
Intensity
Type
Time
• Depending on goal
Primary Prevention: 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
10-minute 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.
SECONDARY PREVENTION
• Cardiac exercise
rehabilitation
programs
• Chronic disease
risk reversal
programs
EPIDEMIOLOGY
• 1900 – 1960: threefold increase in number of heart
disease deaths
• Decrease since 1960s
– Better diagnosis and treatment
– Awareness
– Lifestyle?
EXERCISE AND CAD EPIDEMIOLOGY
Risk of MI in sedentary people 2-3
times that of exercising population
(work or recreation)
Morris 1953, 1973
Blair, Kohl, Paffenbarger 1989
Primary risk factors for CAD in the USA
60
50
40
% of
population at 30
risk
20
High BP
High cholesterol
Cigarette smoking
Physical inactivity
10
0
risk factors for CAD
RISK IN PRIMARY PREVENTION
• PAR-Q
1.
2.
3.
4.
5.
6.
7.
Has your doctor ever said that you have a heart condition and that
you should only do physical activity recommended by a doctor?
Do you feel pain in your chest when you do physical activity?
In the past month, have you had chest pain when you were not
doing physical activity?
Do you lose your balance because of dizziness or do you ever lose
consciousness?
Do you have a bone or joint problem?
Is your doctor currently prescribing drugs for your blood pressure or
a heart condition?
Do you know of ANY other reason why you should not do physical
activity?
INDIVIDUAL RISK
• History
– Risk factors
– Medical history
– Exercise history
– Family history
• Medical examination
• Special investigations
EXERCISE TESTING
• Field tests
– 6 minutes walk
– Unrestricted locomotion test (ULT)
– Coopers incremental test
• Laboratory tests
– ECG stress testing
• submaximal/maximal
– VO2 max
– Lactate threshold
END POINTS/INTENSITY
•
•
•
•
Dyspnoea scale
Symptoms
Rate of perceived exertion (RPE)
Heart rate
PREDICTING HR MAX
• Nonfat men and women:
HR max = 208 – 0.7 X (age, y)
• Body fat > 30%:
HR max = 200 – 0.5 X (age, y)
LOWER AND UPPER LIMIT TRAINING HR
• Method 2: Karvonen method (Heart Rate
Reserve)
– Lower limit target threshold (LLTHR):
• 50% of HRR
– Upper limit target threshold (ULTHR):
• 85% of HRR
• LLTHR = [(HRmax – HRrest) X 0.5] + HR rest
• ULTHR = [(HRmax – HRrest) X 0.85] + HR rest
EXERCISE PRESCRIPTION
ACSM RECOMMENDATIONS
•
•
•
•
Most days of the week, not less than 3
Aerobic exercise
45 minutes (20 – 60)
Low to moderate intensity
– RPE 13 – 16: “fairly light” – “somewhat hard”
– 40 – 80% HRmax
FREQUENCY
• Deconditioned: 2 times per week
• Aim for most days of the week, but at
least three
INTENSITY
• For most individuals intensities within range of 45-70%
HRR or RPE 11-14 are sufficient to achieve
improvements in CR fitness when combined with
appropriate frequency and duration of training
• Start low and increase gradually
• The higher the intensity, the more benefit
TYPE
• Aerobic exercise
– Walking
– Jogging
– Cycling
– Swimming
• Recreational games
• Resistance training?
TIME
• 45 – 60 minutes
– Warm-up – 10 min
– Train at predetermined
intensity – 20-30 min
– Recreational games
– Cool down
– Stretch
PHASES OF PROGRESSION
SECONDARY PREVENTION
• Cardiac exercise
rehabilitation programs
• Chronic disease risk
reversal programs
WHY?
• Reduces death by reinfarction
• Improves quality of life
• Improves functionality
• Reduction of many other
risk factors for CAD
– HPT
– Obesity
– Smoking
COMPONENTS OF CHRONIC DISEASE RISK REVERSAL
•
•
•
•
Referral
Risk stratification
Exercise testing
Exercise prescription
– Phase 1 – 4
• Monitoring
• Dietary assessment and
counseling
• Psychological counseling
• Risk factor education
• Motivational activities,
include family
REFERRAL FOR EXERCISE REHABILITATION
• Why is it not happening?
• How should it be done?
– Rehab centres
– Biokineticists
– Personal trainers
– GP guided
– Patient guided
RISK STRATIFICATION
• Identify presence of CAD risk factors
• Known CVS, pulmonary or metabolic disease
• Signs and symptoms of CVS, pulmonary of
metabolic disease
ACSM RISK FACTOR CATEGORIES
• Low risk
– Men <45, women <55, asymptomatic, no more than one
risk factor
• Moderate risk
– Men >45, women >55, OR two or more risk factors
• High risk
– 2 or more signs and symptoms, or known disease
Post-Myocardial Infarction risk
stratification
Low risk pts
– No complicated factors by day 4
-LVEF > 50%
-No significant ventricular ectopy
Moderate risk pts – Poor ventricular function –LVEF 35-50%
- Severe myocardial ischemia at low levels of
activity after day 4
-ST depression <2mm flat or downsloping
High risk pts
– Sustained myocardial ischemia
- Left ventricular failure, LVEF <35%
- Hypotensive response
- Severe dysrhythmias
CONTRA-INDICATIONS
•
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Unstable angina
BP 200/100mmHg
Aortic stenosis
Acute pericarditis
Debilitating non-cardiac disease
Drop of 20mmHg in resting BP
Uncontrolled atrial tachycardia
Recent pulmonary embolism
3rd degree heart block
Thrombophlebitis
Resting ST segment displacement (>3mm)
Uncontrolled DM
Orthopedic limitations to exercise
MEDICATION AND EXERCISE
• Beta blockers
• Calcium channel antagonists
• Nitrates
PULMONARY REHABILITATION
• Optimize respiratory system medication and technique
• Correction of hypoxaemia
• Desensitization to dyspnoea, fear and other limiting
factors
• Breathing retraining
• Energy conservation
– Balance, coordination, mechanical efficiency, ergonomics
• Exercise training to improve physical deconditioning
PULMONARY REHABILITATION
• Exercise training to improve physical deconditioning
– Oxygen administration when PO2 < 55mmHG or O2 saturation<
88%
– Aim for saturation >90%
• 20 – 30 minutes duration, according to ability
• Interval exercise – 3 sessions of 10 minutes
• Group interaction
TAKE HOME MESSAGE
• Exercise reduce risk of chronic disease in the community
• Chronic disease can and should be treated with exercise
and other rehabilitation modalities
MORE QUESTIONS
•
What is the exercise prescription for primary prevention of coronary artery
disease?
MORE QUESTIONS
•
What is the exercise prescription for secondary prevention of coronary
artery disease?
What if there was
one prescription
that could
prevent and treat
dozens of diseases,
such as diabetes,
hypertension and obesity?
Would you prescribe it to
your patients?
Certainly.
-Robert E. Sallis, M.D., FACSM,
Exercise is Medicine™ Task Force Chairman
DISCUSSION
REFERENCES
•
www.exerciseismedicine.org
•
www.acsm.org/physicalactivity
• Jonas S, Phillips EM, 2009. ACSM’s Exercise is
Medicine – A Clinician’s Guide to Exercise
Prescription. Philadelphia, Lippincott-Williams
THANK YOU!
Dr Louis Holtzhausen
Division Sport and Exercise
Medicine
HoltzhausenLJ@ufs.ac.za