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Exercise as Medicine

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  • 1. “ I have promises to keep, and miles to go before I sleep.” Robert Frost Use of Exercise in Health and Illness Mark Cucuzzella MD FAAFP Associate Professor of Family Medicine West Virginia University Lt Col USAF Reserves Flight Surgeon
  • 2. Objectives
    • Why Exercise?
    • The Art and Science of the Exercise Prescription
    • We will talk more about the art….the science is in the companion article “Exercise as Medicine” posted on the FMDRL
  • 3. Living Proof that Exercise can make up for other bad habits- the Stones 40 yrs later Mick on a hike
  • 4.
    • Co-founder of Nike
    • Inventer of jogging for the masses
    • Built the first real running shoes in his garage
    “ If you have a body you are an athlete” Bill Bowerman
  • 5. 1972 Birth of the Running Boom
  • 6.  
  • 7. Beginnings of the womens’ fitness movement 1984
  • 8. Lifestyle Physical Activity www.americaonthemove.org 10,000 Steps !
  • 9. The Goal I feel great. Is that normal?
  • 10.
    • “ Don't be concerned if exercise will add years to your life...be concerned with adding life to your years." George Sheehan MD
    • "The strenuous life tastes better." William James, 19th Century Philosopher
    • “ If you can’t fly, then run. If you can’t run then walk. If you can’t walk then crawl. But Whatever you do keep moving.” Martin Luther King Jr
    • "Life is motion" Aristotle
    • “ Our growing softness, our increasing lack of physical fitness, is a menace to our security” John Fitzgerald Kennedy
  • 11.
    • "Crumbling is not an instant's Act," Emily Dickinson
    • “ Leave all the afternoon for exercise and recreation, which are as necessary as reading. I will rather say more necessary because health is worth more than learning.” Thomas Jefferson
    • “ Exercise produces order in our affairs, health of body, cheerfulness of mind, and these make us precious to our friends.” Thomas Jefferson
    • “ Lack of activity destroys the good condition of every human being, while movement and methodical physical exercise save it and preserve it.” Plato
  • 12. Quotes From Non-Exercisers
    • “ I consider exercise vulgar. It makes people smell.” Alec Yuill Thornton
    • “ Eat, drink, and be merry, for tomorrow we die.” Unknown
    • “ Exercise is bunk. If you are healthy, you don't need it: if you are sick you should not take it.” Henry Ford
    • “ Whenever I get the urge to exercise, I lie down until the feeling passes away.” Robert M. Hutchins, former President of the Univ of Chicago
  • 13. Quotes From Non-Exercisers
    • The word aerobics comes from two Greek words: aero , meaning "ability to," and bics , meaning "withstand tremendous boredom."
      • Dave Barry
    • I have never taken any exercise, except for sleeping and resting, and I never intend to take any. Exercise is loathsome.
      • Mark Twain, Essays: Seventieth Birthday.
    • I get my exercise acting as a pallbearer to my friends who exercise.
      • Chauncey Depew
  • 14. Quotes From Non-Exercisers
    • I refuse to spend my life worrying about what I eat. There is no pleasure worth forgoing just for an extra three years in the geriatric ward.
      • John Mortimer
    • What some call health, if purchased by perpetual anxiety about diet, isn't much better than tedious disease.
      • George Dennison Prentice
    • Health nuts are going to feel stupid someday, lying in hospitals dying of nothing.
      • Redd Foxx
  • 15. Maybe We’ll Never Have to Walk Again
  • 16. Pachyderm won't pace to keep off pounds A staffer tries to coax Maggie onto her custom treadmill For two months, Maggie's trainers have used her favorite treats -- watermelon, apples, carrots, peanuts in the shell, banana slices and sweet potatoes -- to entice the 8,000-pound elephant into exercising on the $100,000 piece of equipment.
  • 17. Humans Do Not Come in New and Improved Models
    • In health and fitness there is nothing new under the sun
    • Use it or lose it, but use it correctly
    • It’s not rocket science!
  • 18.
    • The "Doc" with Bill Rodgers circa 1975
    • Dr. George Sheehan
    • Cardiologist
    • Exerciser
    • Philosopher
    • “… the effects of training are temporary…I must remain constantly in motion. Otherwise the sedentary life will inexorably reduce my mental and emotional well being.”
  • 19. SOURCE: National Health Interview Survey/CDC % of who engaged in regular leisure-time physical activity US 2001
  • 20.  
  • 21. Belloc and Breslow 7 rules: 1972
    • Results: published 1972 J Pub Health
      • 7000 people surveyed and followed 9 yrs. Adherence to these associated with 11.5 more years of life
    • 1. Eat a Good Breakfast
      • wherever ever hard work is done a good breakfast is served
    • 2. Don’t Eat Between Meals
      • We are responding to messages that aren’t there
  • 22. Breslow 7 rules
    • 3. Maintain Your Weight
      • What did you weigh when you graduated high school, were married, joined the military?
    • 4. Don’t Smoke
    • 5. Drink moderately
    • 6. Get a Good Night’s Sleep
    • 7. Exercise Regularly
      • Use large muscle groups for minimum of 30 minutes 4 times a week
      • pace should be comfortable- middle ground between hard and easy
  • 23. The Talk Test
    • "Comfortable" - a pace determined by consulting your body is the training rate. It is the midpoint on the Borg scale of Perceived Exertion
    • Whatever the activity it should be done comfortably
    • Most people believe the opposite- To be of any value, exercise should be uncomfortable
  • 24. HALE Project- JAMA 2004
    • Study of 2000+ elderly Europeans age 70-90
    • End point is death from heart disease or cancer
    • Mediterranean diet
    • physical fitness
    • moderate alcohol consumption
    • not smoking
    • Individually, they reduced the chance of death by a quarter to a third; together, by close to two-thirds
  • 25.
    • Cardiologist Paul Dudley White*, pioneering fitness advocate of the 1950's, said we should not gain a pound after age 25
      • * Eisenhower’s Cardiologist
    Grandma Age 101 Father in Law Age 85
  • 26. Surgeon General’s Report on Exercise and Physical Activity 1996
    • Exercise is planned repetitive activity
    • Physical activity is energy expenditure by human movement through routine daily activity
    • Recommended regular physical activity
      • 30 minutes of moderate activity five days/week
      • 20 minutes of vigorous physical activity 3 times per week
    • Research has demonstrated that virtually all individuals will benefit from regular physical activity.
  • 27. Surgeon General’s Report on Exercise and Physical Activity 1996
          • Reduces the risk of dying prematurely from heart disease and other conditions
          • Reduces the risk of developing diabetes
          • Reduces the risk of developing high blood pressure
          • Reduces blood pressure in people who already have high blood pressure
          • Reduces the risk of developing colon and breast cancer
          • Helps to maintain a healthy weight
          • Helps build healthy bones, muscles, and joints
          • Helps older adults to become stronger and better able to move about without falling
          • Reduces feelings of depression and anxiety
          • Promotes psychological well-being
  • 28. Does counseling by clinicians improve physical activity? A summary of the evidence for the USPTF Ann Intern Med 2002 Aug 6;137(3):208-15
    • PURPOSE: To determine whether counseling adults in primary care settings improves and maintains physical activity levels
    • CONCLUSION: Evidence is inconclusive that counseling adults in the primary care setting to increase physical activity is effective.
  • 29. Physical Fitness vs Physical Activity
    • Both count- no need to debate this
    • Paffenbarger and Morris - levels of activity associated with protection
    • Blair and Cooper - high levels of fitness by treadmill test decreases mortality
    • Exercise duration on ETT associated with all cause and CV mortality ( Ekelund 1988, Sandvik 1993, Vanhees 1994, Snader 1997, Roger 1998, Wei 1999, Tauqir 2000)
    • Ability to recover inversely related to CV mortality (Cole 1999)
  • 30. Smoking vs Exercise
    • Smokers who are active have 40% lower risk of MI than sedentary non-smokers (Paffenbarger 1978, Hedblab 1997)
    • Physically active smokers live longer than inactive smokers and at least as good as sedentary nonsmokers (Hedblab 1997, Ferrucci 1999)
  • 31. JN Morris Studies
    • Studied 16,000 British civil servants and physical activity in leisure time
    • Heart attack rate in vigorously active group 1/3 of that in less active group
    • Non vigorous activity (walking, golf, dancing ) provided no benefit
  • 32. Ralph Paffenbarger- Harvard Alumni Study
    • Low Leisure time energy expenditure was strong risk factor for first heart attack
    • Only grads who remained active were protected from heart attack
    • Exercise offered protection even in the face of other coronary risk factors
    • Vigorous exercise is best for MI protection
    • Even when they had MI, exercisers had less mortality
  • 33. Ralph Paffenbarger- Harvard Alumni Study
    • Vigorous activity protects against HTN, esp if one is overweight
    • Lifelong vigorous activity adds years to life, and it is never too late
    • Taking up exercise = quitting smoking
    • Stopping exercise = starting smoking
    • Risk of stroke decreased with vigorous activity
    • Depression reduced
    • * Alumni who maintained weight at lowest risk of all cause and cardiovascular mortality
  • 34. Blair, Cooper, and Wei’s Studies
    • Risk reduction occurs with exercise even in the presence of risk factors
    • Fitness level inversely proportional to all cause and CV mortality
    • Increasing fitness level provides protection
    • Sedentary obese at highest risk
    • Exercise can cancel out risk from being overweight
  • 35. Arnold Bennett 1910 in “The Daily Miracle”
    • There are those of us who are always about to live…waiting until things change, until there is more time, until we are less tired, until….
    • We have become civilized animals and have lost the will to survive and the capability of doing so.
    • We want something for nothing…blame others when things go wrong…want the easy way out…deny we have control over our minds and bodies.
  • 36. For Our Patients Why Fitness?.... who cares if you live longer
    • Fitness has to do with the quality of life, not the quantity
    • The effects of fitness on the quality of life are without question
    • People who say they cannot find time to become fit should realize that a fitness program produces more time
  • 37. Changes
    • “ Once you find something that is playful and addictive and filled with satisfaction, your daily budget takes care of itself.” George Sheehan
    • Beware that even minor changes in daily routine are resisted by forces as powerful as any commitment we can make
    • No matter how strong the motivation or commitment- to add a new activity you must take something out
  • 38. If You Take Something Enjoyable Out of Life, You must Put Something of Comparable Enjoyment In
    • Sigmund Freud
      • “ Whoever understands human nature knows that hardly anything is harder for a man to give up than a pleasure he once experienced…Actually we never give anything up. We exchange one thing for another.”
      • smoked through 30 operations on head/neck cancer
  • 39. With Play - Everyone Wins
    • Fitness has to be fun.
    • Play is the process. Fitness is merely the product.
  • 40. “ If it isn’t fun,why do it!" Ben of Ben & Jerry’s Ice Cream
  • 41. U.S. exercise guidelines coming in 2008 POSTED: 7:08 p.m. EDT, October 26, 2006 cnn.com Officials hope federal exercise guidelines will lead Americans to healthier lifestyles, which in turn, could cut health care costs.
  • 42. Simple diet rules - Godfrey Fowlere Oxford University circa 1975
    • 1. The main task is to avoid obesity.
      • This is the provence of exercise. We are not overweight, we are overfat.
      • Only exercise will give us muscle to replace the fat.
      • When you exercise consistently your preoccupation with diet will disappear
    • 2. Average sugar intake should be halve
    • 3. Fat should be reduced to about 30 percent
    • 4. Increase fiber
    • 5. Alcohol should be kept at 2 units a day
  • 43.  
  • 44. Eat a lot of this stuff
  • 45. If You Exercise You Can Eat This Stuff! Roberta’s Shrimp Scampi Grandma’s Calamari
  • 46.
    • When asked if he carried a notebook to write down new ideas Einstein replied that he did not get many new ideas.
    • When faced with a problem chances are the solution lies not in a new idea but in taking a new look at a old one.
  • 47. Covert Bailey “Fit or Fat” 1970 Book now on third edition- not much has changed over 5 million copies sold
    • Exercise the ONLY cure for obesity
    • Not concerned with weight- emphasis on fitness
    • obesity= excess body fat
    • Observed most fat people eat less than skinny people
    • Diet alone will not do the job- reduces muscle as well as fat
  • 48. Covert Bailey “Fit or Fat” 1970
    • Stop shooting for an ideal weight
    • Shoot for health, become aerobically fit- the fat will take care of itself
    • Indicators of progress:
      • measurements of waist, thighs, hips
      • Cooper 12 minute test
    • “ The choice is yours… It has not been tried and found wanting. It has been found difficult and left untried” Sheehan
  • 49. Is it Better to Be Fit and Fat or Thin and Unfit?
  • 50. Obesity, Fitness Level, and CVD Mortality (Blair et al., 1999) *Referent group is Moderate-High Fitness Level
  • 51.  
  • 52. Exercise as Relaxation
    • “ Exercise …..is the ultimate tranquilizer.” George Sheehan
    • Relaxation techniques- nothing new is discovered, nothing has radically changed
    • In exercise one can play, move, create, contemplate, discover, reach…
  • 53. We Need the Physical Stress
    • Today’s society full of mental stress—but void of physical stress
    • Physical stress must be self administered
    • Nietzsche “What does not destroy me makes me strong”
    • Stress is a necessity for good life- Welcome it because without it we would not be at our best
    • “ It is well known that exercise is the best tranquilizer. I refuse to medicate patients until they give aerobic exercises an adequate trial.” Dr. Alan Clark (psychiatry)
  • 54.
    • important for the White House team to exercise on regular basis
    • better worker if you exercise on a daily basis
  • 55. Dick Probably Needs to Go on Some Rides Too
  • 56. Do You Need a Guru to Pump You Up?
  • 57. Is Fitness a High Tech Industry?
    • All you need is a mirror, a scale, tape measure, and watch
      • What does your reflection tell you? Good news if most of fat is on belly- it will come off rapidly
      • Match your weight against what is was when you were last active and athletic
      • As you become fit muscle will replace fat
      • Measure calves, thighs, hips, waist, and chest
      • How far can you go in 12 minutes? AM pulse?
  • 58. Cardiopulmonary Fitness or Muscular Fitness?
    • Exercise offers some improvement in the functioning of the heart and lungs ~20%
    • Huge improvements in muscles~ 300%
    • Capillaries multiply, mitochondria enlarge, enzymes increase
    • Heart is the fuel pump to an efficient engine- conditioned muscles do more with less
    • Cardiac and Pulmonary rehab are really muscular rehab
  • 59. Cardiac Rehab Most cardiac rehab patients are self-referred
  • 60. Got Lungs?
  • 61.
    • Got Legs?
    • A good pair will help you deal with almost any disease process
  • 62. Disease vs Illness
    • Disease is a biological process
    • Illness is the impact the disease has on the patient’s life
    • There are instances where the disease may not be improved in any way, yet treating the illness and the patient’s life situation can give almost miraculous results
    • We know too much about disease and too little about health
  • 63.  
  • 64.
    • 1. Exercise- mix of aerobic and weight bearing exercise
    • 2. Stress Management
    • 3. Nutrition- goal of healthier eating
  • 65.
    • “ Before cancer I was always worrying about what I was going to be doing 5 or 6 years down the road. That’s bulls----. It’s a terrible way to live. When I was sickest I decided, I’m never going to waste another day thinking about tomorrow. This is it. Today is all I have.”
  • 66. The Original Lance Armstrong- Terry Fox
  • 67. Never Give Up…..Jimmy V Mike Mann Age 37 Dx: NSC Lung CA 2006 USA National Cross Country Championship 4 Months after chemo Battling 2 nd relapse now
  • 68.
    • Lived 5 yrs longer than doctors prognosis
    • Completed NYC Marathon
    • when he should have been dead
  • 69. Why Don’t Hospitals Have Fitness Programs?
    • Why don’t we use exercise as medicine?
    • We know pathology- how will body movement change the inevitable progression?
    • Less than 4 hours of 4 years of medical school spent on effects of exercise
    • We know little of exercise physiology and how exercise will benefit every patient regardless of the disease
  • 70. Treat the Whole Patient- But How?
    • Exercise good for diabetes, but better for the person with diabetes…good for hypertension, but better for the person with hypertension…
    • Whether final prognosis of disease is changed is not the main concern
    • Fitness will push back barriers of fatigue -it is separate from disease
  • 71. Doctors
    • Good at dealing with acute illness
    • Fail in treatment of chronic disease
      • High tech laboratory, xray, procedures offer little help here
      • Fight in the trenches with relentless foe
      • Role is coach, motivator, teacher
  • 72. You’d love my doctor. His creed is rest, rest, and more rest.
  • 73. Aging
    • “ Most people live nowhere near their limits. They settle for an accelerated aging, an early and precipitous fall. They give aging a bad name. Too many people entering their forties are performing at physiological levels more appropriate to somebody sixty years old.” George Sheehan
    • Physicians primarily concern themselves with chronologic age
  • 74. Cape Canaveral, Florida 1962 “ I believe that the Good Lord gave us a finite number of heartbeats and I'm damned if I'm going to use up mine running up and down a street.” Neil Armstrong on jogging
  • 75.
    • Shuttle Mission STS-95 at age 77 would not have been possible without attention to exercise and diet
    • The Senator said an important part of his regimen has always involved exercises anyone can do, such as jogging and brisk walks, and has not relied on high-tech equipment or training
  • 76. If you didn't know your chronological age, how old would you be?
    • Fit individuals show only a five percent loss in endurance per decade after 30.
      • world records for the 40 age-group fall within 5 percent of actual world records.
      • At age 50, they come within 10 percent.
      • At age 60, they are close to 15 percent.
    • Statistics clearly show that apparent aging can be blamed largely on inactivity
    • Active 60-year-old and inactive 30-year-old have equal physical work capacity
  • 77. Ed Whitlock Age 75 2:55 Marathon Fauja Singh Age 92 5:40 Marathon
  • 78. “ It’s remarkable Mr. Volmer. You have the clothes of a man half your age”
  • 79. Obstacles
    • Boredom- the feeling of wanting to be somewhere else
    • How do you feel at home in a fitness program?
      • It must be interesting, satisfying, filled with pleasure and excitement
      • Dissociation- allowing the mind to wander
      • Ask pts-Are you so boring you cannot spend a half hour a day with yourself?
  • 80. Exercise Kept These POW’s Alive for up to Seven Years in 10 x 6 Cells Operation Homecoming 1973
  • 81. Obstacles ?
  • 82. Psychology
    • Regiment people- it is easy to get them fit
    • Get them to do it on their own- tough
    • Exercise vs Play vs Sport
    • “ Exercise is work…it is anything a body does not want to do” Mark Twain
    • Exercise has purpose but no meaning
    • Play and sports have meaning but no purpose
    • Few will exercise for any length of time without additional motive of play and sport
  • 83. 6 AM with the 101st Airborne
  • 84. Physical Education
    • Basic to education of aristocrats ( arete to fulfill one’s function) in ancient Greece, in Florence during the Renaissance, for Thomas Jefferson, in turn of the century Europe and America, for US military academies
    • “ The body is the source of all energy and initiative” Plato
    • “ I hope that the ideal of the well trained and vigorous body will be maintained neck and neck with that of the well trained and vigorous mind.” William James 1896
  • 85. Start With the Kids-Play!
  • 86.  
  • 87. Appeal to a Higher Value
    • There has to be something more valuable than medical rewards touted by experts
    • Must be relationship between exercise and everyday performance that is immediate and direct- looking better, feeling better…..
    • Fitness programs should not be torture- but an interesting and happy time
  • 88. Appeal to Passion
    • Will not find motivation in what is rational
    • Passion allows one to face and revel in stress
    • Become engaged - make the fitness experience a deeper part of the senses
    • Become aware - a fit mind and body will harmonize
    • “ I can’t wait to get out on the roads to find out what I’m going to think about” Dr. Tom Tutko, sports psychologist
  • 89. Life is not a Spectator Sport
    • We are constantly being warned to check with our physicians before beginning activity. Play and games evidently can be risky business.
    • What we are not told are the risks of not beginning activity-that the most dangerous sport of all is watching it from the stands.
  • 90. Doctor's Orders?
    • Less than 30 percent of doctors advise their patients about exercise and nutrition (CDC-HP 2010)
    • “ Doctors are trained to fight disease, not prescribe health. I've had more than one doctor ask me if I'm amazed that my knees haven't given out yet.” Bill Rodgers in the Idiots Guide to Jogging and Running
  • 91. Whenever any runner dies, for whatever reason, some reporter will march out the name of Jim Fixx and suggest that running is to blame 1976
  • 92. Why do so many say that you should run only with a note from your doctor?
    • Running portrayed inaccurately in the media
    • Every year 30,000 + people run the New York City Marathon
    • Every 5-10 years one has a heart attack during the race and dies
    • This tragedy is what gets play in the papers
    • University of Michigan's home football games, the medical teams expect to treat two heart attack patients per game from the stands
  • 93. Running and Heart Attacks
    • Moderate run will increase risk of a heart attack by 5 to 7 times vs sitting in a chair
    • Heart attack lifetime risk 70% lower in most fit vs least fit
    • “ If your goal is to survive the next hour then sit in the chair. But if your goal is to live a long healthy life then get some exercise for the next hour” Paul Thompson MD- Cardiologist
  • 94. Be like the Eagle They do not like to travel in flocks
  • 95.
    • Feel the wind in your hair and the sand beneath your feet
    Great Sand Dunes
  • 96. Walk the Walk…. Nearing the top of Pike’s Peak Colorado….I need Oxygen!
  • 97. Exercise Prescription- The Science
    • The most thorough evidence based review and practical guideline on exercise prescription was published in March 2006 and is available free online http://www.cmaj.ca/
    • Warburton et al; Prescribing exercise as preventive therapy. Can. Med. Assoc. J., Mar 2006; 174: 961-974
  • 98. Exercise Prescription- The Science
    • Benefits achieved through variety of activities at variety of intensities
    • Light to moderate activity most days of the week
    • Should not be complicated
    • Tailored to activities the patient enjoys and can achieve in activities of daily living
    • 20 to 60 minutes of activity most days of the week is all that is needed, the higher the intensity the less time required.
    • Activity need not be structured
    • Goal 1000 kcal of energy expenditure a week- but lower levels provide health benefit, esp. in elderly and deconditioned.
  • 99. Example ( see CMAJ article for charts of energy expenditure for many activities )
    • 50 yo Family Physician (weight 70kg) desires to regain his “college physical condition”….or at least where he was when he graduated med school.
    • Preferred activities: moderate intensity 3-5 days a week (jogging), and light activity daily (walking dog)
    • Exercise prescription:
    • Jogging for 30 min 3 days per week:
    • 3 x 245 kcal/session = 735 kcal
    • Walking dog 20 min/day:
    • 7 x 70 kcal/session = 490 kcal
  • 100. Going Beyond Fitness
    • Fitness is a measurable ability to do work
    • There is a dose/response
    • Think of ourselves as athletes
    • Other less important activities will not interfere with your activity
    • Strive for maximum output- not minimum requirements
  • 101.
    • In 1967, at the age of 20, Ms. Switzer became the first woman to run the Boston Marathon wearing official numbers. When a race official spotted her, he tried to rip off her numbers and throw her out of the race—because she was a woman. But Ms. Switzer finished the race.
    • "That accomplishment changed my life and gave me a tremendous sense that there was nothing in the world I couldn't do"
  • 102. May‑6, 1954 By the end of 1957, 16 runners had logged sub-4-minute miles 3:59.4 - physiologic and psychological barrier.
  • 103.  
  • 104. MLK Jr (Apr 3 1968: his last speech)
    • “ Like anybody, I would like to live a long life. Longevity has its place. But I’m not concerned about that now. I just want to do God’s will, and He’s allowed me to go up to the mountain. And I’ve looked over. And I’ve seen the promised land.”
  • 105.
    • Luke Skywalker: “I don’t believe it!”
    • Yoda: “That is why you fail.”
  • 106. Questions

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