christoph gutenbrunner - health prevention

Health prevention – from the

viewpoint of medicine

Christoph Gutenbrunner

Christoph Gutenbrunner, MD, PhD, Professor

Department for Rehabilitation Medicine

Institute for Balneology and Medical Climatology

Hanover Medical School

D-30625 Hannover

[email protected]

Health prevention – from the viewpoint of medicine


16th Annual ESPA Congress

Belek, May 25th, 2011

Overview

Health prevention: what is it?

Chronic health conditions: how do they begin?

Recovery and Adaptation: how does it work?

Health prevention: what are the strategies?

Health resort: why to go there?

Effects: do we have any scientific evidence?

Conclusions: what are the preconditions?





Health strategies: ICHA-HC (OECD 2001; 2010)





Health prevention: ICHA-HC (OECD 2001)

Prevention and public health services:

◦ Maternal and child health

◦ Family planning and counselling

◦ School health services

◦ Prevention of communicable diseases (e.g. vaccination)

◦ Prevention of non-communicable diseases

- public health services of health education, disease prevention

(incl. Interventions against smoking, alcohol abuse)

- services provided by self-help groups; general health education

and health information (incl. campaigns in favour of

healthier life-styles, safe sex, etc.)

◦ Occupational health care

◦ All other miscellaneous public health services






Health prevention in health resorts may aim at

◦ diagnosis and assessement of risk factors (e.g. physical

inactivity, obesity and metabolic syndrome,

distress, smoking etc.)

◦ reducing risk factors (e.g. weight reduction, blood

pressure normalisation, stop smoking etc.)

◦ health education (reducing risk behavior, supporting

healthy life style)

◦ normalise autonomuos dysfunction and enhance physical

capacity (both cardiovasular and muscular

performance)

◦ improve mood, energy and drive





Chronic health conditions: how do they

begin?





Metabolic syndrome in obesity

0

50

100

150

200

250

300

350

400

450

500 Plasma glucose

0

20

40

60

80

100

120

140

160

180

200

220

Plasma insulin blood sugar

regulation

in the i.v.-glucose-

tolerance test

(5th min)

Normal body weight

Overweight

n=16, each

Data from

Melani et al. (1967)





Chronic health conditions: how do they begin?

Risk factors for chronic health conditions (examples)

◦ physical inactivity

◦ unhealthy food

◦ distress

◦ smoking

Early signs for chronic health conditions (examples)

◦ insuline resistance

◦ blood pressure dysregulation

◦ muscle weakness

◦ reduced airway clearance

Conclusion: most chronic health condition initially start from

dysregulation of autonomous functions





Recovery and Adaptation: how does it

work?






Short-term recovery (minutes)

◦ recovery of local metabolic processes

Sleep-wakefulness (day)

◦ recovery of autonomous functions

Functional adaptation (weeks)

◦ improvement of autonomous regulation

Trophical adaptation (months)

◦ growth of (specific) tissues

Neuroplasticity (months to years)

◦ enhancement of neuronal functions





Functional adaptation

Functional adaptive processes evoked by balneological

stimuli may lead to adaptive normalization of functions

controlled by the autonomous regulation system

◦ e.g. cardio-respiratory, metabolic, digestive or immune

functions

Adaptive normalization is formally characterized by

◦ convergence of functional parameters

◦ aiming at normal values

◦ coincidence of normal values with functional optima





Adaptive normalisation (blood pressure)

Systo

lic b

loo

d p

res

su

re [

mm

Hg

]

Days of treatment

Hypertension

(n=8)

Normal blood

pressure (n=80)

Low blood

pressure (n=16)

Gutenbrunner &

Ruppel: Phys

Med Rehab Kuror

1992; 2: 58-64





Initial values (classes of 10 mmHg) days 1-3

Ch

an

ge o

f b

loo

d p

ressu

re (

lin

ear

reg

ressio

n)

days 4

-28

Normalisation

of the systolic

blood pressure

Target value

Norm

al ra

nge

Decre

ase

Inc

reas

e

Gutenbrunner

& Ruppel:

Phys Med

Rehab Kuror

1992; 2: 58-64

Adaptive normalisation (blood pressure)





Reaction time

Patients

Controls

optical

acoustical

Shimmer test

Days of treatment

Fre

quency [H

z]

Reaction tim

e [m

s]

Cited from: Gutenbrunner &

Hildebrandt: Handbuch der

Balneologie und medizinischen

Klimatologie, Springer 1998

Reactive periods (vigilance functions)





Long-term effects (physical working capacity)

Group 1 (n = 17)

Group 2 (n= 45)

W1

30

[% o

f in

itia

l va

lue]

Weeks Months after end of treatment

Cited from:

Gutenbrunner C,

Hildebrandt G:

Handbuch der

Balneologie und

medizinischen

Klimatologie, Springer

1998





Study on body weight changes

Aim of the study: formal evaluation of the body weight changes

undergoing complex spa treatment

Patients: 646 patients undergoing spa treatment in Bad

Wildungen, most of the because of musculoskeletal

problems (low back pain, cervical pain, osteoarthritis of

knee and or hip)

Inclusion: consecutive patients (with wide range of body weight)

Evaluation:

◦ Daily blood pressure measurements

◦ Body weight at the begin and at the end of treatment





Changes of body weight

Gutenbrunner C, Ruppel K: Akt

Ernähr Med 1992; 17: 8 (1992).

Ch

an

ge o

f b

od

y w

eig

ht

[kg

]

Deviation from normal weight [%]

(begin of treatment)





Body weight changes and calorie intake

Gutenbrunner C, Ruppel

K: Akt Ernähr Med 1992;

17: 8 (1992).

Ch

an

ge o

f b

od

y w

eig

ht

[kg

]

Deviation from normal weight [%]

(begin of treatment)

Diet:

2300 kcal/day

1000 kcal/day

800 kcal/day






Short-term recovery (one night of good sleep; relaxation at weekend)

lead to improvement of body functions, well being and

performance but does not normalize autonomous regulation

Long-term recovery or functional adaptation (three to six weeks of

adaptation) improve regulation capacity

◦ physical and psychological stress can be compensated

◦ performance is increase for many months

◦ risk factors may be reduced

Long-term training (mostly more than six weeks of adaptation) increases

capacity of specific functional tissues (muscle strength, bone

density and others)





Health prevention: what are the

strategies?





Health prevention: what are the strategies?

Analizing risk factors and diagnosing early signs of chronic

diseases (check-up)

Improving autonomous regulation by functional adaptation and

increase performance

Training to compensate insufficient functions

Teach health generating factors and pathophysiological knowledge

Enable persons to handle with stress

Modify behavior aiming at reducing risk behavior and support

healthy living






Specific health promoting factors

◦ climate

◦ landscape, training facilities

Expertise to solve the problem and to treat the health condition and

means to do so , e.g.

◦ doctors, psychologists, therapists, dieticians

◦ baleotherapy, physiotherapy, training

Environment supporting well-being, e.g.

◦ scenery and architecture

◦ cultural events, places for spirituality





Balneotherapy: modalities

Substances, e.g.:

◦ Mineral waters (Na, Ca, Mg, Cl, SO4, H2S, CO2, trace elements)

◦ gases (CO2, H2S, Rn)

◦ peloids (mud, peat, fango and others)

Modes of application, e.g.:

◦ bathing

◦ drinking

◦ inhalation

Dosage, e.g.:

◦ single use

◦ series

◦ combination

Gutenbrunner C et al.:

J Biometeorol 2010;

54: 459-507





Effective factors of health resort treatments

Health resort medicine: performance of comprehensive medical

concepts for prevention, therapy and rehabilitation including

◦ medical examination

◦ balneotherapy

◦ hydrotherapy

◦ physiotherapy

◦ diet

◦ psychotherapy

◦ education

◦ change of environment

◦ climate

◦ cultural factors

◦ and others

Gutenbrunner C et al.:

J Biometeorol 2010;

54: 459-507





Effects: do we have any scientific

evidence?





Lower Saxony Cardiovascular Prevention Study

Aim of study: Are inpatient rehabilitative measures effective in

patients with an elevated cardio-vascular risk factor

profile?

Design of study: Prospective controlled study

Inclusion criteria: At least two cardiovascular risk factors or

LDL<135 mg%

Intervention: Three weeks inpatient rehabilitative measures in a

specialized rehab centre including physical medicine,

balneotherapy, diet and health education

Controls: Care of their family doctors





Parameters: Metabolic risk factors, blood pressure, behavioral

risk factors (diet, stress behavior), psychometric variables

Time points: Two weeks before (T1), two weeks after (T2) and

one year after the treatment or control period (T3)

(all measurements were carried out at day-to-day-

conditions)

Number of cases:

◦ Includes cases: n = 199 (49 women, 150 men)

◦ Drop outs: n = 23

◦ evaluable cases:

- study group: n = 82

- control group: n = 94






Parameter p-value ( T1-T2) p-value ( T1-T3)

Overall effect p = 0,000*) p = 0,020*)

BMI [kg/m2] p = 0,000**) p = 0,021**)

Apolipoprotein B [mg/dl] p = 0,015**) p = 0,008**)

Fasting insulin [mg/dl] p = 0,035**) p = 0,034**)

Fibrinogen [mg/dl] p = 0,950**) p = 0,215**)

Mean arterial blood pressure [mmHg] p = 0,002**) p = 0,101**)


Gutenbrunner et al.: Phys Med Rehab Kuror 2001; 12: 272-283





-15

-10

-5

0

5

10

p<0,05

[mg/dl]

Change of

Apolipo-

protein B

diffe

rence

control group

(n=82)

study group

(n=71)

0,0

0,1

0,2

0,3

0,4

0,5

0,6

T1-T2 T1-T3T1-T2 T1-T3

Effect size

eff

ect

siz

e

Gutenbrunner et al.:

Phys Med Rehab Kuror 2001; 12: 272-283






-2,0

-1,5

-1,0

-0,5

0,0

0,5

1,0

p<0,001

[kg/m²]

Change

of BMI

diffe

rence o

f B

MI

control group

(n=50)

study group

(n=49)

0,0

0,1

0,2

0,3

0,4

0,5

0,6

T1-T2 T1-T3T1-T2 T1-T3

Effect size

eff

ect

siz

e

Gutenbrunner et al.:

Phys Med Rehab Kuror 2001; 12: 272-283






Renal stone formation metaphylaxis study

Design of the Study:

◦ Controlled study, cross-over-design

Patients:

◦ Patients with multi-episodic CaOx-urolithiasis (n=34)

Setting:

◦ Everyday activities, nutrition protocol

Intervention:

◦ 1.5 l/d bicarbonated water (2,673 mg HCO3/l)

◦ 1.5 l/d low-mineralized water (98 mg HCO3/l)

Main Outcome Parameters:

◦ urinary pH, magnesium- and citrate excretion

◦ CaOx supersaturation





1,0

1,5

2,0

2,5

3,0

3,5

4,0

******

[l]

Patients with Recurrent Urolithiasis

n = 34

Urinary

Volume

Baseline

Controls

Baseline

Bicarbonate Water

5,5

6,0

6,5

7,0

***

*

Urinary

pH

1,0

1,5

2,0

2,5

3,0

3,5

4,0

4,5

******

Supersaturation

CaOx

Karagülle et al.,

World J Urol 2007;

25: 315-323

Renal stone formation metaphylaxis study





Germa Spa Visit Study





Effects: do we have any scientific evidence?

It has been shown that serial application of belnotherapy and

exercise can induce functional adaptation leading to

improved autonomous regulation (with long-term effects)

Clinical preventions studies show that systematic and medically

driven health resort interventions lead to a reduction of

cardiovascular risk factors and increase physical

performance (long-tem effects)

Clinical studies with patients show beneficial effects of balneo-

therapy and health resort medicine on pain in muskulo-

skeletal disorders (e.g. low-back-pain, osteoarthritis), mental d

isorder (anxiety, depression) and others (skin disorders,

cardiovascular disorder, airway disease)





Conclusions: what are the

preconditions?





Conclusions: what are the preconditions?

For health prevention health resorts must provide:

◦ Medical check-up done by a doctor

◦ individual prevention plan

◦ balneotherapy according to individual need (prescription!)

◦ supervised exercise treatment

◦ dietary programs

◦ health education programs

Clients must

◦ actively participate in the program

◦ stay long enough (3 to 6 weeks)

From the medical perspective outcome research is a must!





Christoph Gutenbrunner, MD, PhD, Professor

Department for Physical Medicine and Rehabilitation

Institute for Balneology and Medical Climatology

Hanover Medical School

D-30625 Hannover

[email protected]

christoph gutenbrunner - health prevention

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