Week 5 - Exercise is Medicine Flashcards
we are in a Global epidemic of Inactivity
responsible for cancer and heart disease
5 leading causes of death:
1) High BP
2) Tobacco use
3) High blood glucose
4) Physical inactivity
5) overweight/obesity
Physical activity is FOURTH leading cause of premature death
plan calls for 10% reduction by physical inactivity by 2025
Contributors to Overall Health Status
Environment contains social supports, employment, education, etc.
50% Health Behaviours (Exercise, Smoking, Diet)
20% Genetics
20% Environment
10% Access to Medical Care
Physical Activity
“in view of the prevalence, global reach and health effect of physical inactivity, the issue should be appropriately described as pandemic, with far-reaching health, economic, environmental, and social consequences” - the lancet
*This is the problem*
Exercise is Medicine Canada
Originally from US
Movement to encourage a healthy lifestyle among Canadians
Programs are based on abundant evidence the physical activity and exercise reduce the risk of chronic disease and the belief that:
Exercise is Medicine Belief
- most canadians can find simple ways to incorporate physical activity and exercise into their daily routines;
- more should be done to address physical activity and exercise in the healthcare setting; physical activity and exercise should be incorporated as a key health indicator and standard of medical care as a ‘vital sign’
- certified exercise professionals serve as important resources for Canadians and their healthcare providers
EIM Exercise Prescription & Referral Tool
- Reduce sedentary behaviour and physical inactivity recommendations
- Recommending how much exercise
- More likely to comply/adopt behaviour change if doctor tells it
- If exercise was a drug, it would be the most effective
Exercise Prescription and Referral Sheet
- reduce sedentary behaviour options
- physical activity recommendations
exercise is effective. if exercise was a drug, it would be one of the most effective and safe ways to prevent and treat many chronic diseases such as heart disease, hypertension, diabetes, osteoporosis, anxiety disorders and depression
Secondary Prevention Outcomes
- Delayed birth
- Lower disease recurrence
- Lower disease severity
- Fewer hospitalizations (‘events’)
- Fewer procedures
- Fewer medications/lower doses
- Higher HR-QoL
- Improved biomarkers/clinical risk factors
- Faster return to work/life
- System cost-savings
Best Way to increase PA
start slow and low
- Do it more often, eat better, and do more
Exercises Immunity & COVID-19
Exercise instantaneously mobilizes immune cells
Exercise & Immunity
- Having higher age and sex-adjusted scored for cardiorespiratory fitness (CRF) and performing regular exercise of moderate- to vigorous-intensity exercise (within ACSM guidelines)
- improves immune responses to vaccination
- lowers chronic low-grade inflammation
- improves immune markers in several disease states including cancer, HIV, cardiovascular disease, diabetes, cognitive impairment and obesity.
Exercise, Immunity, & COVID-19
- PA has positive effects on normal functioning of immune system, especially for older adults (>65years).
- Contracting skeletal muscle releases cytokines that promote T-cell and NK-cell maintenance and trafficking.
— Can help sore need by having more resources readily available (not having to fight other shit)
Beneficial effects of exercise likely offer protection against SARS CoV2 and may help boost immune responses to a future vaccine, protecting vulnerable populations from COVID-19.
Exercise training and CRF
- Exercise training and CRF: promote maintenance of the peripheral T-cell pool—
- lower infection risk
Based on what we know…
- 30-60 minutes of moderate-intensity exercise 3-5 days per week can help boost/ maintain immune function
- Even a 30-minute brisk walk provides immediate immune benefits that can last for several hours afterwards.
- Up to 72 hour layover
-
Caution: Unaccustomed high volume, high-intensity exercise training that far exceed recommended guidelines may stress the immune system.
– Extreme either way negatively affects you
Comparative Effectiveness of Exercise and Drug Interventions on Mortality Outcomes: Meta-epidemiological Study
- Meta-analysis of 16 studies (4 exercise, 12 drug) that compared the effectiveness of exercise interventions vs. drug therapy
- Exercise and drug interventions did NOT differ in terms of mortality benefits or in:
– secondary prevention of coronary heart disease
– rehabilitation after stroke,
– treatment of heart failure, and
– prevention of diabetes
– In some cases, like stroke rehabilitation, exercise intervention was more effective!
Meta-epidemiological Study CONCLUSIONS
- Exercise and many drugs are similar in terms of their benefits
- Exercise interventions SHOULD be considered as a viable alternative to, or alongside, drug therapy
- PHYSICAL ACTIVITY needs to become the prescribed “PILL” of the future!
Regular Exercise on Low Back Pain Reduction
- Early data suggests 40% reduction in self-reported pain aerobic exercise;
- but little evidence
Cancer: Increases in HR-QoL
Physical Activity and Depression & Anxiety
- 1 in 5 adults will experience anxiety or depression in their life
- Significantly higher for university students — we also have better statistics for this population
- Unless you report mental health as primary reason for visit, will not be reported
– Anxiety: reduces symptoms as much as drugs
— Stubbs et al., 2017
— An examination of the anxiolytic effects of exercise for people with anxiety and stress-related disorders: A meta-analysis
— Fewer anxiety symptoms for exercise group
— Even walking can alleviate symptoms
Reduction in Depressive Symptoms
- Schuch et al., 2016 Meta-analysis
- _Aerobic training MOST effective_ But all types beneficial
- Recommend first line monotherapy for mild to moderate depression
- Can be used alongside primary therapy for severe (drugs or CBT) — Combination for severe
- Need to monitor closer
- May take a few weeks — 4-6 weeks to start seeing effects
- Just as effective as drugs
Exercise for Anxiety/Depression: How does it work?
1) physiological mechanisms
2) psychological mechanisms
3) inflammatory mechanisms
Physiological Mechanisms
ie. action of endorphins, elevation of body temp, function of mitochondria and neuroplasticity, and changes in serotonin
Psychological Mechanisms
ie. distraction or mental time out, master and self-efficacy
Inflammatory Mechanisms
ie. evidence of a link between the immune system and the nervous system
Physical Activity & Depression
Article: Bushman (2019), American College of Sports Medicine Journal
- Q: Is physical activity of any benefit in preventing or treating depression?
1) >20% of adults 18-49yo experience major depressive episode (USA, ‘17)
2) Treatment is often delayed/absent (e.g., medication, CBT)
3) Aerobic exercise (and possibly resistance exercise) reduces symptoms as much as meds/CBT
4) In a few weeks, ≥30min x ≥3 days/week reduces odds of experiencing depression by 48% (and dose-response relationship)
Physical Activity & Type 2 Diabetes
- Patho-physiology — the PROBLEM for health care
– More individuals are entering the health care system who are sedentary, obese, becoming frail and requiring chronic disease prevention and management care. - Pre-diabetes — don’t have it yet but on your way
– Lifestyle adjustments very important here - Body does not like it when blood glucose rises
– Tries desperately to get it out
Diabetes: microvascular complications
- Leading cause of blindness, end-stage renal disease, non-traumatic amputations
- Cardiovascular disease leading cause of death for people with diabetes
– 2-4X more likely - 1 in 4 die with diabetes
UK Prospective Diabetes Study
- Reduce blood sugar, A1C levels reduce micro and macro complications
- Each 1 point (1%) reduction, very huge benefits
Robert E. Sallis, MD, FACSM - EIM Advisory Board Chair
“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!”
Step 1: Lifestyle Interventions
- 0.5 reduction with aerobic alone; resistance training alone
- Benefits additive combined = 1.0%!!!
- Not common knowledge
Immediate Benefits — lower your blood glucose within 1 hour
- improve your mood, sleep patterns and energy level
- increase the effectiveness of the insulin your body makes or the insulin your doctor prescribes for you
Long-term Benefits — improve your blood glucose control
- reduce your body fat
- help keep your pancreas, kidneys, eyes and nerve healthy
- reduce the risk of heart attack, stroke, and death
Reading Highlights
- PA reduces A1C and serious T2D complications
- Both aerobic and resistance type exercise; Yoga and Aquafit class work, too!
- Limiting sitting time is important (stand every 30mins)
- Make it stick! E.g., count steps
- Exercise prescription examples
Physical Activity & Heart Disease
- Perfusion (blood flow by mass) is not equal to blood flow
- Ischemic = limitation of blood flow to heart
– Plaque buildup
– Lack of exercise and poor diet
Strict Bed Rest Policy
NOT GOOD
Cardiac Rehabilitation
“the enhancement and maintenance of cardiovascular health through individualized programs designed to optimize physical, psychological, social, vocational, and emotional status
“the facilitation and delivery of secondary prevention through risk factor identification and modification in an effort to prevent disease progression and recurrence of cardiac events”
Cardiac Rehabilitation
up to 45-60 min/day
- 2-3 RT
- 2-3 flexibility
Quit smoking, eat healthier, add a little exercise; more likely to take medication
Exercising a little bit, more likely to adopt healthier behaviours
PERIPHERAL benefits
FASTER than central benefits
- improve skeletal muscle
CENTRAL benefits
take longer, need more commitment
- greater ejection fraction — takes 6 MONTHS
can you stabilize heart disease or plaque development with exercise?
YES!!
- Less than 30 min a week, slow down but still progress
- 45 min / week stop development
- Accumulate 90 min 5 days a week, expect to see plague shrink
- More the better
- A lot of exercise; built low and slow
Exercise and progression of coronary atherosclerosis
- stabilization 1500 kcal/week
- progression <1400 kcal/week
- regression 2200 kcal/week (90 min/day)
Exercise can reduce and reverse the complications and damage
- difference is emergency room visit
CVD: Survival Benefits
- Exercise can be cornerstone whether or not you are going to survive
- Less than 5% died if you participated; did not 10%
- Mortality or comorbidity side effects with exercise and heart disease is important to remember
Is exercise really like medicine?
YES!
Exercise is Medicine - End Goal
No patient should leave the clinic without:
- An assessment of their physical activity levels, and
- Brief advice/physical activity Rx and/or a referral to
qualified programs or professionals for further support
Communities provide:
- Evidence-based, effective and accessible PA interventions for referred patients.
- Safe, inviting and well-maintained spaces for recreational activities and active transportation
What type of physical activity has been shown to improve immune response to vaccines?
BOTH ACCUTE & CHRONIC
Onset of depression is lower when:
participants increased their physical activity over time
T/F:
A lot of patients prefer the side effects of exercise rather than pharmaceuticals (e.g., nausea, lethargy, etc.) for treatment.
TRUE
Exercise is Medicine is a global health initiative and has been adopted in Canada as a movement to encourage a healthy lifestyle among Canadians.
Their belief is:
Most Canadians can find simple ways to incorporate physical activity and exercise into their daily routines.
Problems with exercise and depression trials
ability to “blind” participants is not possible;
finding a true exercise placebo is difficult;
control group improvement is common
exercise effects would need to match or supersede those found in the placebo/control in order for exercise to be considered a successful intervention
Effects of exercise larger for…
individuals with major depressive disorder
improvements greatest when…
supervised by exercise professionals
aeorbic exercise
improved depression
- both equipment and equipment-free; inside and outside hospital, indoors outdoors, in groups and solo, differing severity although weaker for greater severity
Is exercise a treatment option for depression?
Yes
- works well as mono-therapy or adjuvant to medication in moderate depression
to retain mental health benefits, _exercise must be MAINTAINED_
evidence for exercise in treatment of MDD is presented at level 1 (top level of evidence)
first-line monotherapy for mild and moderate MDD
second-line adjunctive treatment of moderate to severe MDD
Duration suggestions
30 min+ 3 days a week for at least 8 weeks
30-40 min 3-4 days per week at low to moderate intensity
persistent sub-threshold symptoms
group settings with a competent practitioner
3 sessions per week, 45-60 min in length, over 10-14 week period
potential equal effectiveness between aerobic and anaerobic but more evidence needed
individuals with depression die how much earlier than those without?
10 years
*PA has potential to help with treating symptoms of depression while also promoting overall health, thus reducing mortality”
design considerations
1) risk stratification given incidence of chronic disease
2) fitness assessment and exercise perceived exertion
3) examination of perceived barriers and benefits of exercise, along with discussion of strategies for success
PA reduces the RISK and SYMPTOMS
dose-response relationship for depressive symptoms
even lower levels than recommended can have benefit
PA is AS EFFECTIVE AS medication and CBT
GRADUAL increase in PA is recommended
improvements in depression usually take time!
PA and Diabetes: Key Messages
- moderate to high levels of PA and cardiorespiratory fitness associated with substantially lower morbidity and mortality in people with diabetes
- both aerobic and anaerobic are beneficial; optimal to do both
- strategies to increase self-efficacy and motivation to increase uptake
- type 2 diabetes, supervised exercise particularly effective in improving glycemic control, reducing need for non-insulin hyperglycaemic agents and insulin, producing modest but sustained weight loss
- habitual prolonged sitting is associated with increased risk of death and major cardiovascular events
Key messages for people with diabetes
- improves glycemic control and facilitates weight loss, other health benefits even if these 2 don’t change
- best to avoid prolonged sitting… get up briefly every 20-30 min
- 150 min per week aerobic exercise
- step monitor can help track (pedometer or accelerometer)
- 2 days per week strength training
- doing smaller amounts of activity sill has some health benefits
aerobic exercise
continuous, rhythmic movements of large muscle groups, normally at least 10 min at a time
resistance exercise
involves brief repetitive exercises with weights, weight machines, resistance bands, or own body weight to increase muscle strength and or endurance
flexibility exercise
aims to enhance the ability to move through fuller ranges of motion
yoga
both resistance and flexibility exercise
Benefits of PA
- supervised improve AIC glycated hemoglobin, triglycerides, and cholesterol
- reduce cardiovascular and overall mortality
- aerobic increases cardiorespiratory fitness in both type 1 and 2; slows development of peripheral neuropathy
- more than 150 min / week = greater A1C reductions and HIGHER intensity
- type 1, no demonstrated beneficial effect on glycemic control
- lowered A1C children and youth and lowered BMI, TG, and total cholesterol levels
- inverse association between PA and A1C, ketoacidosis, BMI dyslipidemia, hypertension, retinopathy, micoalbuminuria
high intensity-interval training
a type of aerobic exercise training based on alternating between short periods of vigorous intensity exertion and periods of rest of lower-intensity exercise; commonly performed using a predominantly aerobic exercise modality, such as running or cycling
maximum oxygen uptake
maximum rte of oxygen utilization during exercise
benefits of interval training
high intensity = greater gains in cardiorespiratory fitness, improves glycemic control
- type 1 less risk for hypoglycaemia than continuous aerobic, at least during time of activity
- twice weekly = reduced abdominal fat and visceral fat significantly but continuous aerobic exercise did not
benefits of resistance training
improves glycemic control, decreases insulin resistance and increases muscular strength, lean muscle mass, and bone mineral density… enhanced functional status and prevention of sarcopenia and osteoporosis
greatest impact: progress to 3 sets 8 reps at moderate to high intensity 3 times per week or more
Type 1, improved body composition and strength, enhanced insulin sensitivity, possibly modest reductions A1C; associated with less hypoglycemia risk
combination resistance and aerobic
significant reductions in A1C and body fat
*EFFECTS ARE ADDITIVE*
benefits of other types of exercise
tai chi no effect AIC
yoga weak evidence reductions in A1C
water-based PA, encouraged for people with comorbidities; improves A1C
supervised vs. unsupervised exercise
supervised: improved glycemic control in adults with type 2 diabetes
unsupervised: exercise improved glycemic control only if there was concomitant dietary intervention
less supervision = less beneficial impact on glycemic control, insulin resistance, and body composition than studies with greater supervision
supervised aerobic and resistance exercise training had significantly better results, including greater reductions in A1C, blood pressure, BMI, waist circumference, and estimated 10-year CV risk, and greater increases in aerobic fitness, muscle strength, and high-density lipo-protein cholesterol
the look-AHEAD trial
Action for Health in Diabetes
175 min/week of unsupervised exercise was targeted as part of intense lifestyle intervention
CV event rates were not significantly different
significantly greater and more sustained improvements in many important secondary outcomes, including
- weight loss;
- improved cardiorespiratory fitness,
- improved glycemic control, - BP and lipids with fewer medications,
- decreased rate of sleep apnea,
- severe diabetic chronic kidney disease and retinopathy,
- depression,
- sexual dysfunction,
- urinary incontinence,
- knee pain,
- better physical mobility maintenance and
- quality of life,
- with lower overall healthcare costs
Minimizing risk of exercise-related adverse events
Identifying individuals for whom medical evaluation should be considered prior to initiating an exercise program
- middle and older adults with diabetes who want to engage in very vigorous or prolonged exercise
- (pre)proliferative retinopathy
- severe retinopathy
resting ECG, exercise stress ECG test for those with typical or atypical chest discomfort, unexplained dyspnea, peripheral arterial disease, carotid bruits, history angina, MI, stroke, TIAs
*exercise testing is poor predictor of future cardiovascular disease events
screened for signs and symptoms consistent with myocardial ischemia, such as chest pain, severe shortness of breath upon exertion and/or syncope
cardiac evaluation prior to participating
Minimizing risk of exercise-related adverse events
minimizing risk of heat-related illness
healthy over age 40 and those with diabetes have restricted capacity to lose heat — reductions in heat loss responses of sweating and skin blood flow
- reduced physical fitness further exacerbates
- heat stress is associated and increase in disease-related symptoms
- exercise should be performed indoors in a cool and dry and well-ventilated environment if it is very hot outside
- conducted in early or later hours when temperatures are cooler and sun is not at its peak
- prolonged exercise interspersed with adequate rest or break periods in a shaded or cool location
- avoid performing exercise in hot humid conditions
- stay well hydrated
Minimizing risk of exercise-related adverse events
minimizing risk of exercise-induced hypoglycemia in type 1
*prolonged aerobic exercise increases insulin sensitivity in recovery for up to 48 hours
- consumption of extra carbohydrates for exercise, limited bolus insulin doses, reducing the basal insulin rate for continuous subcutaneous insulin fusion
- increase cars right before, during, immediately after simple and effective way to prevent
- perform intermittent brief (10 sec) maximal-intensity sprints either at the beginning or end or during moderate intensity workout
- resistance training immediately before aerobic also helps
- exercise performed late in day or evening can be associated with increased risk of overnight hypoglycemia
Minimizing risk of exercise-related adverse events
minimizing risks related to hyperglcemia
glucose levels can rise with brief intense exercise, such as sprinting, resistance training, 10-15 min of maximal-intensity aerobic exercise to exhaustion or high intensity interval training for type 1
type 2, ensure proper hydration and monitor for signs and symptoms of dehydration, especially in the heat
type 1, if ketone levels are elevated, vigorous should be postponed until insulin is given
- negative or “trace” and person feels well, it is not necessary to defer exercise due to hyperglycemia
reduction of sedentary behaviour
interrupting sitting by light walking or light resistance training can attenuate postprandial increases in BG, insulin, and TG
- PA levels and sedentary behaviours should be considered distinct and potentially independent behaviours
use of adjunct motivational interventions to improve PA uptake
increases PA self-efficacy and motivation - increase self-reported & objectively assessed PA
goal setting, problem solving, providing info, and self-monitoring have some efficacy to increase PA and improve A1C
motivational interviewing
goal-oriented, client-centered counselling style, which helps to explore and resolve ambivalence and increase intrinsic motivation in individuals in order to change behaviour
motivational communication
represents a collection of evidence-based strategies drawn from motivational interviewing, CBT and behaviour change therapies
- used as a communication strategy to engage individuals in changing their behaviours
pedometer
- wearable device that detects and counts each step a person takes
objective monitoring of PA
accelerometer
- device that measures nongravitational acceleration
objective monitoring of PA
pedometer vs. accelerometer
both well suited to measuring walking or jogging, but not bicycling or swimming
pedometer measures STEPS NOT speed
accelerometer measures STEPS AND SPEED
objective monitoring of PA
- inverse relationship higher self-reported walking with CV events and both CV and all-cause mortality in type 2 diabetes
- 1 year intervention was 1200 steps/day higher in active arm
- pedometer-based facilitator-led group programs increase step count by 2000 steps/day over 3-6 months
Recommendation 1
accumulate minimum of 150 minutes of mod-vig aerobic exercise each week; at least 3 days a week; no more than 2 consecutive days without exercise to improve glycemic control, reduce risk of CVD and overall mortality
SMALLER AMOUNTS CAN BE BENEFICIAL TO LESSER EXTENT
Recommendation 2
Interval training recommended to people willing and able to perform it to increase gains in cardiorespiratory fitness in type 2 diabetes and to reduce risk of hypoglycemia during exercise in type 1
Recommendation 3
should perform resistance training at least twice a week, preferably 3x
initial instruction and periodic supervision by an exercise specialist can be recommended
Recommendation 4
should minimize the amount of time spent in sedentary activities and periodically break up long periods of sitting
Recommendation 5
setting specific exercise goals, problem solving potential barriers to PA, providing information, self-monitoring should be performed collaboratively
Recommendation 6
step count monitoring with a pedometer or accelerometer can be considered in combination with physical activity counselling, support and goal-setting to support and reinforce increased physical activity
Recommendation 7
reduce risk of hypoglycemia:
- reduce the bolus dose of insulin that is most active at time of exercise
- significantly reduce basal insulin for exercise duration
- increase carb consumption
- perform brief maximal intensity sprints
- perform resistance training before aerobic
Recommendation 8
over 40 who want to undertake vigorous exercise should be assessed for conditions that might put them at increased risk with history, physical exam, resting ECG, exercise ECG stress test
Recommendation 9
structured exercise programs supervised by qualified trainers should be implemented when feasible for type 2 diabetes to improve glycemic control, CV risk factors, and physical fitness
Promoting Adherence
adherence is key
- use positive cues to be more active and remove cues that cause inactivity
- set realistic goal that gives direction and motivation
- find ways to make exercise rewarding with positive reinforcement
- recruit social support
- identify resources in the environment that support activity
- develop a plan to deal with barriers or interruptions in exercise plans
