exercise is medicine: moving your patients to better health
TRANSCRIPT
Exercise is Medicine: Moving your Patients to Better Health
Deepak S. Patel, MD, FAAFP, FACSM, CIC
Director of Sports Medicine, Rush Copley Family Medicine Residency, Aurora, ILAssistant Professor, Rush Medical College, Chicago, IL
Medical Director, Rush Copley Sports Medicine, Aurora, IL
Family Medicine and Sports Medicine, Yorkville Primary Care, Yorkville, IL
Disclosure
It is the policy of the AAFP that all individuals in a position to
control content disclose any relationships with commercial
interests upon nomination/invitation of participation. Disclosure
documents are reviewed for potential conflicts of interest and, if
identified, conflicts are resolved prior to confirmation of
participation. Only those participants who had no conflict of
interest or who agreed to an identified resolution process prior to
their participation were involved in this CME activity.
All individuals in a position to control content for this session have
indicated they have no relevant financial relationships to disclose.
Learning Objectives
1. Outline the minimum exercise recommendation for all age
groups.
2. Design individualized exercise prescriptions with
consideration to the FITT-VP principle.
3. Identify strategies to address patient barriers to
participating in an exercise program.
Overview
Trends Benefits Amount Barriers
Exercise
2020 Fitness Trends
1) Wearable technology
2) High-Intensity interval training (HIIT)
3) Group Training
4) Training with free weights
5) Personal training
6) Exercise is medicine
7) Bodyweight training
8) Programs for older adults
9) Health/wellness coaching
10)Hired certified fitness professionals
11)Functional fitness training
Thompson, WR. WORLDWIDE SURVEY OF FITNESS TRENDS FOR 2020. ACSM's Health &
Fitness Journal 2021;(22):10-19.
High Intensity Interval Training (HIIT)
▪More time efficient
▪Benefits in overweight/obese: ➢ fasting blood glucose
➢ waist circumference
➢ resting heart rate
➢ systolic blood pressure
Batacan RB, Duncan MJ, Dalbo VJ, et al. Effects of high-intensity interval training on
cardiometabolic health: a systematic review and meta-analysis of intervention studies Br J
Sports Med 2017;51:494-503
BMI or Fitness
▪ 14,345 men (mean age 44 years) ▪ Independent & combined association changes fitness/BMI
in all-cause & CVD mortality▪ Every 1-MET improvement = 15% lower CVD & 19% lower
all -cause mortality▪ BMI change no benefit with all-cause or CVD mortality▪ Losing fitness inc. higher all-cause & CVD mortality risks
regardless of changes in BMI
Lee et al. Changes in Fitness and BMI, and Mortality Circulation. 2011;124:2483-2490.
BMI or Fitness for Mortality
Lee et al. Changes in Fitness and BMI, and Mortality Circulation. 2011;124:2483-2490.
BMI or Fitness for CVD Mortality
Lee et al. Changes in Fitness and BMI, and Mortality Circulation. 2011;124:2483-2490.
All Cause Mortality and Activity
SEDENTARY SOME ACTIVITY
MINIMUM ACTIVITY
FIT
4.32
1.81 1.31 1
RE
LA
TIV
E R
ISK
Myers, Jonathan et al. Improved Reclassification of Mortality Risk by Assessment of Physical Activity in Patients Referred for
Exercise Testing Am J Med. 2015 Apr;128(4):396-402. doi: 10.1016/j.amjmed.2014.10.061. Epub 2014 Dec 12.
AES Question
Question 1
▪Exercise Benefits?
▪Benefits beyond weight loss, Htn, lipids, CAD, DM?
Benefits/Contraindications
Benefits
▪ TNTC
▪ For everyone
Contraindications
▪ Start slow, progress
▪ Unstable angina
Benefits
▪ All cause and disease specific mortality▪ Risk of cancers of the bladder, breast, colon,
endometrium, esophagus, kidney, lung, and stomach▪ Cognition▪ Quality of life▪ Anxiety/depression▪ Improved sleep▪ Weight Management (slowed weight gain, and avoid regain)▪ Weight loss, (combined w calorie reduction)
Piercy KL, Troiano RP, Ballard RM, et al. The Physical Activity Guidelines for Americans. JAMA. 2018;320(19):2020–
2028. doi:10.1001/jama.2018.14854
Benefits- older adults
▪Cognition
▪Risk of dementia (including Alzheimer disease)
▪Quality of life
▪Sleep
▪Bone health
▪Physical function (ADL)
▪Risk of falls (older adults)
▪Risk of fall-related injuries (older adults)Piercy KL, Troiano RP, Ballard RM, et al. The Physical Activity Guidelines for Americans. JAMA. 2018;320(19):2020–
2028. doi:10.1001/jama.2018.14854
Benefits- Children
▪Bone health
▪Weight
▪Cardiorespiratory & muscular fitness
▪Cognition
▪Risk of depression
▪Academics
Piercy KL, Troiano RP, Ballard RM, et al. The Physical Activity Guidelines for Americans. JAMA. 2018;320(19):2020–2028. doi:10.1001/jama.2018.14854
Singh A., et. Al. Effects of Physical Activity interventions on Cognitive and Academics BJSM 2019
Haverkamp B, Wiersma R, et. Al. Effects of physical activity interventions on cognitive outcomes and academic performance in adolescents and young
adults: A meta-analysis. J Sports Sci. 2020;38(23):2637-2660. doi:10.1080/02640414.2020.1794763
Benefits – Depression
▪ Exercise alone reduces symptoms of depression (SOR: B). ▪ As effective as CBT, meds (SOR: B, meta-analysis). ▪ Cochrane: equal to meds and CBT (SOR: A).▪ Resistance & aerobic exercise better than aerobic exercise
alone (SOR: B, meta-analysis). ▪ Resistance exercise alone effective for symptom
improvement (SOR: A)
Alan Gill, MD; Rosalind Womack, MD; Sarah Safranek, MLIS; Does exercise alleviate symptoms of depression? Jfam
Pract September 2010 · Vol. 59, No. 09: 530-531
Cooney GM, Dwan K, Greig CA, Lawlor DA, Rimer J, Waugh FR, McMurdo M, Mead GE. Exercise for depression.
Cochrane Database of Systematic Reviews 2013, Issue 9. Art. No.: CD004366. DOI:
10.1002/14651858.CD004366.pub6
Anxiety-Systematic Review
▪Exercise training lasting < 12 weeks, session > 30 min ▪ Significantly reduced anxiety symptoms, especially
if symptoms > 1 week
▪Systematic Review: ▪Effective adjunctive treatment ▪Less effective than antidepressants ▪Aerobic & non-aerobic exercise effectively reduce
The Effect of Exercise Training on Anxiety Symptoms Among Patients; Matthew P. Herring, MS, MEd; Patrick J. O’Connor, PhD;
Rodney K. Dishman, PhD; Arch Intern Med. 2010;170(4):321-331.
Jayakody K, Gunadasa S, Hosker C. Exercise for anxiety disorders: systematic review Br J Sports Med 2014;48: 187–196.
Type 2 Diabetes
▪ 20 Inactive diabetics: A1c >7; 10-week program ▪ Treadmill exercise vs. strength training effects on A1C. ▪ Resistance training group had reduction in HbA1c of 18% vs 8% for the treadmill
group
▪ JAMA: 262 sedentary men/ women HbA1c > 6.5% in 9-month exercise program ▪ Compared w/ control, change in HbA1c in combination training exercise was −0.34% ▪ Mean changes in HbA1c not statistically significant in either the resistance training
(−0.16%) or the aerobic (−0.24%) groups vs. control group ▪ Combination of resistance training with cardio exercise improves A1C in Diabetics
better than either cardio or resistance training alone (SORT: B)
•Bweir S, Al-Jarrah M, Almalty AM, et al. Resistance exercise training lowers HbA1c more than aerobic training in adults with type 2
diabetes. Diabetol Metab Syndr 2009;1:27
•Church TS, Blair SN, Cocreham S, et al. Effects of aerobic and resistance training on hemoglobin A1c levels in patients with type 2
diabetes: a randomized controlled trial. JAMA. 2010;304(20):2253–2262.
Type 2 Diabetes
▪Glucose & Lipids benefit
▪Exercise after meals better than prior
▪Exercise in Evenings better than AM
Heden, T., Kanaley, J. Syncing Exercise With Meals and Circadian Clocks. Exerc. Sport Sci Rev Vol. 47, No. 1, pp 22-28, 2019 doi:
10.1249/JES.0000000000000172
Pre-Diabetes
▪ Medication (Metformin) vs. lifestyle program1
▪ >7% weight loss &
▪ >150 minutes exercise/week
▪ Medication reduced Diabetes in 31%
▪ Lifestyles reduced Diabetes in 58%
▪ Inverse association between step counts and subsequent risk of a
cardiovascular event2
▪ Womens Health Study: Strength training=30% risk reduction (17% CVD
reduction)31. Knowler WC, Barrett-Connor E, Fowler SE, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med.
2002;346(6):393–403.
2. Yates T, et. Al.; Association between change in daily ambulatory activity and cardiovascular events in people with impaired glucose tolerance
(NAVIGATOR trial): a cohort analysis. Lancet. 2014 Mar 22;383(9922):1059-66. doi: 10.1016/S0140-6736(13)62061-9. Epub 2013 Dec 20.
3. Shiroma E. et al. Strength Training and the Risk of Type 2 Diabetes and Cardiovascular Disease. Med Sci Sports Exerc. 2017 Jan;49(1):40-46.
Benefits – Viral Infections
▪12-week study
▪43–46% lower in high vs low
aerobic activity/fit level
▪URTI severity and
symptomatology were reduced
▪Lower risk of severe Covid 19
David C Nieman, Dru A Henson, Melanie D Austin, et al. Upper respiratory tract infection is reduced in physically fit and active adults Br J Sports Med published
online November 1, 2010 doi: 10.1136/bjsm.2010.077875
Sallis, R. Young DR, Tartof SY, et al Physical inactivity is associated with a higher risk for severe COVID-19 outcomes: a study in 48 440 adult patients BJSM
Published Online First: 13 April 2021. doi: 10.1136/bjsports-2021-104080
Exercise vs. Medications
▪ 305 RCTs mortality outcomes of coronary heart disease, pre-diabetes, stroke, heart failure (CHF)
▪ Equal in secondary prevention of CAD and pre-diabetes ▪ Exercise more effective in stroke▪ Diuretics more effective in CHF
Naci H., Ioannidis JPA. Comparative effectiveness of exercise and drug interventions on mortality outcomes: metaepidemiological study.
BMJ 2013;347:f5577.
Exercise vs Meds for BP
▪All patients, meds better reduction of BP
▪ In Htn, Exercise = most meds
▪Endurance = resistance
Naci H, Salcher-Konrad M, Dias S, et al. How does exercise treatment compare with antihypertensive medications? A network meta-
analysis of 391 randomised controlled trials assessing exercise and medication effects on systolic blood pressure
Br J Sports Med Published Online First: 18 December 2018. doi: 10.1136/bjsports-2018-099921
Exercise & Lipids: the sooner, the better
Reverses Middle age risk and HF
▪RCT
▪Healthy sedentary 45-64 y/o
▪2 yrs of supervised high intensity exercise
▪Reversed cardiac stiffness
▪Reduced risk of HF
Howden EJ, et .al. Reversing the Cardiac Effects of Sedentary Aging in Middle Age-A Randomized Controlled Trial: Implications For
Heart Failure Prevention. Circulation. 2018 Jan 8. pii: CIRCULATIONAHA.117.030617. doi: 10.1161/CIRCULATIONAHA.117.030617.
[Epub ahead of print]
Improve Genetic Risks▪Grip strength, physical activity, & cardiorespiratory fitness inverse
risk of CAD, Afib.,
▪Greater grip strength & fitness= lower CAD, Afib. At all genetic risk levels
▪High Genetic Risk & high levels of cardiorespiratory fitness:▪ 49% lower CAD
▪ 60% lower Afib.
Tikkanen, E., Gustafsson, S., Ingelsson, E. Associations of Fitness, Physical Activity, Strength, and Genetic Risk With
Cardiovascular Disease: Longitudinal Analyses in the UK Biobank Study Circulation. 2018; CIRCULATION AHA.
117.032432, originally published April 9, 2018. https://doi.org/10.1161/CIRCULATIONAHA.117.032432
Exercise Benefits: Video games
▪ 15 min HIT exercise
▪ League of Legends gaming
▪ Improved performance
de Las Heras, Bernat, et al. "Exercise Improves Video Game Performance: A Win–Win Situation." Medicine & Science in Sports &
Exercise (2020)
What and How Much Exercise to Prescribe
Exercise Rx: FITT-VP
▪Frequency-how often (3-5x/week)?
▪ Intensity-moderate/vigorous, pace?
▪Type-what is pt able/willing to do
▪Time-how much (30-50 min/ session)▪ 10 min/session minimum total 150 min/week
▪Volume
▪Progressive-increase time and/or intensity
Minimum Recommendations – Adults
All adults 18-65 y/o:▪ Strength-training:
8-10 exercises, 8-12 repetitions of each exercise 2 days/week.
▪ Cardio: Moderate intensity
30 min./day, 5 days/week (150 -300min total/wk) (SOR: B);
ORVigorous intensity 25 min./day, 3 days/week (75-150 min total/wk)
▪ (May divide cardio exercise sessions into multiple >10 minute blocks to total recommended time)
Piercy KL, Troiano RP, Ballard RM, et al. The Physical Activity Guidelines for Americans. JAMA. 2018;320(19):2020–2028.
doi:10.1001/jama.2018.14854
Bull FC, Al-Ansari SS, Biddle S, et al World Health Organization 2020 guidelines on physical activity and sedentary behaviour British Journal of
Sports Medicine 2020;54:1451-1462.
Minimum Recommendations – Older Adults
▪All adults >65 y/o:▪ If at-risk of falling - balance exercises
AND
▪ Have a physical activity plan
▪As for others:▪ Do moderate intense cardio 30 min/day, 5 days/week
ORDo vigorous, intense cardio 25 min/day, 3 days/weekAND
▪ Do 8-10 strength-training exercises, 8-12 repetitions of each exercise twice a week
Piercy KL, Troiano RP, Ballard RM, et al. The Physical Activity Guidelines for Americans. JAMA. 2018;320(19):2020–
2028. doi:10.1001/jama.2018.14854
Children’s Recommendations
Children 6-17 y/o:
▪ Muscle/Strength-training: 3 days/week
▪ Cardio: Moderate or Vigorous: 60 minutes every day
▪ Vigorous > 3 days/week
Piercy KL, Troiano RP, Ballard RM, et al. The Physical Activity Guidelines for Americans. JAMA. 2018;320(19):2020–2028. doi:10.1001/jama.2018.14854
Bull FC, Al-Ansari SS, Biddle S, et al World Health Organization 2020 guidelines on physical activity and sedentary behaviour
British Journal of Sports Medicine 2020;54:1451-1462.
Moderate Intensity (30 min, 5 days/week)
▪ Walking (brisk)▪ Dancing▪ Bicycling 5-9 mph, level▪ Aerobics▪ Swimming, recreational ▪ Tennis, doubles ▪ Gardening▪ Household chores
▪ Scrubbing floors ▪ Washing windows
▪ Mowing lawn
▪ Actively playing w/kids▪ 3-5 METs
Exercise Timing vs. Sitting
▪ Sitting > 8 hrs. per day= incrmortality risk
▪ Reversed w/ mod intensity exercise 60-75 min/day
▪ 1-2 exercise sessions reduce CVD & all cause mortality
Ekelund, et. Al. Does physical activity attenuate, or even eliminate, the detrimental association of sitting time with mortality? A harmonised meta-analysis of
data from more than 1 million men and women. The Lancet, 2016; DOI: 10.1016/S0140-6736(16)30370-1
O’Donovan G, Lee IM, Hamer M, Stamatakis E. Association of “weekend warrior” and other leisure time physical activity patterns with risks for all-cause,
cardiovascular disease, and cancer mortality. JAMA Intern Med. 2017;177(3):335–42.
SHIROMA, et. Al. Physical Activity Patterns and Mortality: The Weekend Warrior and Activity Bouts. Med. Sci. Sports Exerc., Vol. 51, No. 1, pp. 35–40,
2019.
Physical Activity Time and Mortality
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0.4
0.6
0.8
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0 0-7.5 7.5-15 15-22.5 22.5-40 40-75 >75
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Arem H, Moore SC, Patel A, et al. Leisure Time Physical Activity and Mortality: A Detailed Pooled Analysis of the Dose-
Response Relationship. JAMA Intern Med. Published online April 06, 2015. doi:10.1001/jamainternmed.2015.0533.
Exercise Intensity Maters
▪ 403K patients
▪ 50-70% vigorous exercise= 17 % dec. all cause mortality
Wang Y, Nie J, Ferrari G, Rey-Lopez JP, Rezende LFM. Association of Physical Activity Intensity With
Mortality: A National Cohort Study of 403 681 US Adults. JAMA Intern Med. 2021;181(2):203–211.
doi:10.1001/jamainternmed.2020.6331
Vigorous Intensity (25 min, 3 days/week)
▪ Large increase in breathing or heart rate (conversation is difficult or “broken”)
▪ Jogging or running ▪ Swimming laps ▪ Tennis, singles ▪ Bicycling ≥ 10 mph ▪ Circuit training ▪ Moving furniture ▪ Mowing lawn, hand mower ▪ ≥ 6 METs
AES Question
Question 2
▪ List Barriers to Exercise?
Top reasons adults are not more
physically active1,2
Tips to counter
Time Set a schedule, prioritize, mornings,
Inconvenient Encourage 10 minute bursts
Motivation Consider benefits
Not enjoyable Try different exercise options, classes,
active hobbies
Find exercise boring Try active games
Lack Confidence in ability to be active Utilize educational resources or
professional trainer
Injury fears Address physical restrictions and
progress gradually
Unable to set goals and monitor progress
toward a goal
Assist to set smaller short term and
longer term goals
Lack encouragement and support Involve friends and family
Access to facilities within a convenient
distance
Consider walking, home, or work
options
1. Sallis J.F., Hovell M.F. (1990) Determinants of exercise behaviour. Exercise and Sport Science Reviews 18, 307-330
2. Sallis J.F., Hovell M.F., Hofstetter C.R. (1992) Predictors of adoption and maintenance of vigorous physical activity in men and women. Preventive
Medicine 21, 237-251
Barrier to exercise?
$$ for Exercising?
44
Apps, Video Games, Videos?
Inexpensive
Year-round
No/little equipment
Motivating
Fitness Monitors
▪ Popular▪ Synchronize activity schedule,
heart rate, diet changes, etc.▪ Can complete with others▪ $$$▪ Behavior change in elder
adults1▪ younger adults, no advantage
vs standard behavioral 2
1. Mercer K, et. al. Behavior Change Techniques Present in Wearable Activity Trackers: A Critical Analysis. Eysenbach G, ed.
JMIR mHealth and uHealth. 2016;4(2):e40. doi:10.2196/mhealth.4461
2. Jakicic JM, Davis KK, Rogers RJ, et al. Effect of Wearable Technology Combined With a Lifestyle Intervention on Long-term
Weight Loss: The IDEA Randomized Clinical Trial. JAMA. 2016;316(11):1161-1171. doi:10.1001/jama.2016.12858.
Step Counts Count, NOT intensity?
Steps vs Mortality across the agesSteps vs mortality in > 40 y/o
Saint-Maurice PF, Troiano RP, Bassett DR, et al. Association of Daily Step Count and Step Intensity With
Mortality Among US Adults. JAMA. 2020;323(12):1151–1160. doi:10.1001/jama.2020.1382
Online Resources
▪ CDC: https://www.cdc.gov/physicalactivity/index.html
▪ NIH:
https://www.nhlbi.nih.gov/health/educational/lose_wt/phy_act.htm
▪ AAFP: http://www.aafp.org/patient-care/public-health/fitness-
obesity/tips.html
▪ ACSM every body walk: http://www.acsm.org/about-
acsm/initiatives/every-body-walk
▪ Exercise is medicine:
http://www.exerciseismedicine.org/support_page.php/healthcare-
providers/
Other Resources
▪National Institute on Aging free book
▪https://www.nia.nih.gov/health/publication/exercise-physical-activity/introduction
Starts with us?What do we tell patients?
▪ Incorporate & schedule exercise into our day
▪The more you move, the more you burn & improve your health
▪Simple things: Park farther, ▪ Use stairs vs. elevator
▪Exercise regularly
Are We Accountable To Our Patients?
▪ Newsweek Mar 26, 2007: "What Do the Doctors Do? They know whatsgood for us when it comes to exercise, but do they follow their own advice? Read all about it"
▪ "A survey of primary-care physicians several years ago found that doctors who regularly get aerobic exercise are more likely to counsel their patients about its benefits. We wouldn't want it any other way. Fair or not, people still hold doctors to high standards. Maybe it goes back to "physician, heal thyself": if you are going to tell me what to do, for goodness' sake, you'd better do it yourself. "
▪ The Atlantic, Jun 12, 2012: "Doctors, Practice What You Preach"
▪ "If they can't do it, how can I?"
Best Practice Recommendations▪Exercise has numerous benefits for our
patients (SORT: A)
▪Utilize FITT-VP to prescribe exercise (SORT: B)
▪Be creative to overcome barriers (SORT: C)
Need more motivation?
Additional References
▪ http://www.acsm.org/AM/Template.cfm?Section=Home_Page&TEMPLATE=/CM/HTMLDisplay.cfm&CONTENTID=7764
▪ Physical Activity Counseling, Am Fam Physician. 2008;77(8):1029-1136, 1138.▪ http://www.guideline.gov/summary/summary.aspx?doc_id=10477&nbr=5500&ss=6&xl=9
99▪ http://www.aafp.org/afp/20021115/usx.html▪ Weidinger,et. al; How to make exercise counseling more effective: Lessons from rural
America J. Fam Prac 57:6; 6/1/2008, 394-400▪ http://www.cdc.gov/nccdphp/dnpa/physical/everyone/▪ http://www.cdc.gov/nccdphp/dnpa/physical/everyone/get_active/overcome.htm▪ www.Execiseismedicine.org▪ Bravata DM, Smith-Spangler C, Sundaram V et al. Using pedometers to increase
physical activity and improve health: a systematic review. JAMA 2007; 298:2296–2304.▪ Lee PG, Jackson EA, Richardson CR. Exercise Prescriptions in Older Adults. Am Fam
Physician 2017 Apr 1;95(7):425-432.▪ Piercy KL, Troiano RP, Ballard RM, et al. The Physical Activity Guidelines for Americans.
JAMA. 2018;320(19):2020–2028. doi:10.1001/jama.2018.14854
References▪ Batacan RB, Duncan MJ, Dalbo VJ, et al. Effects of high-intensity interval training on cardiometabolic
health: a systematic review and meta-analysis of intervention studies Br J Sports Med 2017;51:494-503
▪ Piercy KL, Troiano RP, Ballard RM, et al. The Physical Activity Guidelines for Americans. JAMA.
2018;320(19):2020–2028. doi:10.1001/jama.2018.14854
▪ Wang Y, Nie J, Ferrari G, Rey-Lopez JP, Rezende LFM. Association of Physical Activity Intensity With
Mortality: A National Cohort Study of 403 681 US Adults. JAMA Intern Med. Published online November
23, 2020. doi:10.1001/jamainternmed.2020.6331
▪ Bull FC, Al-Ansari SS, Biddle S, et al World Health Organization 2020 guidelines on physical activity and
sedentary behaviour British Journal of Sports Medicine 2020;54:1451-1462.
▪ Wang Y, Nie J, Ferrari G, Rey-Lopez JP, Rezende LFM. Association of Physical Activity Intensity With
Mortality: A National Cohort Study of 403 681 US Adults. JAMA Intern Med. 2021;181(2):203–211.
doi:10.1001/jamainternmed.2020.6331
▪ Thompson, WR. WORLDWIDE SURVEY OF FITNESS TRENDS FOR 2020. ACSM's Health & Fitness
Journal 2021;(22):10-19.
▪ Singh A., et. Al. Effects of Physical Activity interventions on Cognitive and Academics BJSM 2019
▪ Haverkamp B, Wiersma R, et. Al. Effects of physical activity interventions on cognitive outcomes and
academic performance in adolescents and young adults: A meta-analysis. J Sports Sci.
2020;38(23):2637-2660. doi:10.1080/02640414.2020.1794763
Answers
1. No Correct Answer
2. No Correct Answer
