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PHYSICAL ACTIVITY IN THE MANAGEMENT OF  ABDOMINAL OBESITY Robert Ross, PhD School of Kinesiology and Health Studies,  Department of Medicine, Division of Endocrinology and Metabolism  Queen’s University Kingston, Ontario, Canada
Overview ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Prevalences of Adult Overweight and Obesity in Canada, 2004 ,[object Object],59%
[object Object],The percentage of patients in each of the 9 groups is shown. Prevalence of Diabetes Across Waist Categories and Body Mass Index (BMI) subgroups in 99 Thousand Women Waist circumference tertile (cm) BMI category (kg/m 2 ) Frequency (%) <25 ≥ 30 25-30
Waist Circumference (WC) Predicts Diabetes Beyond  Commonly Evaluated Cardiometabolic Risk Factors ,[object Object],Number of cardiometabolic risk factors Odds ratio for diabetes p trend <0.001 for both WC and risk factors Low WC Moderate WC High WC
Add Waist Circumference to Routine Allied Health Care To help identify the high-risk, abdominally  obese patient.
Health Risk in Adults According to Body Mass Index (BMI) and Waist Circumference
Abdominal Obesity and Cardiometabolic Risk Intra-abdominal fat is a  strong correlate of cardiometabolic risk Intra-abdominal or visceral fat INSIDE OUTSIDE
Waist circumference and intra-abdominal (visceral) fat  should be  primary targets  for strategies designed to reduce obesity and related comorbidities.
Overview ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Question Is it also possible to observe meaningful reduction in waist circumference, intra-abdominal fat and insulin resistance in response to exercise with no change in  body weight? Is it possible to observe meaningful reduction in waist circumference, intra-abdominal (visceral) fat and insulin resistance in response to exercise with substantial (>5%) weight loss? YES
Treatment Subject  recruitment Random allocation 1. Control 2. Diet weight loss 3. Exercise weight loss 4. Exercise without weight loss Effects of Diet or Exercise With or Without Weight Loss on Abdominal Obesity and Insulin Resistance ,[object Object],[object Object],[object Object]
Effects of Diet or Exercise with or Without Weight Loss  on Abdominal Obesity and Insulin Resistance ,[object Object],[object Object],Control Diet weight loss Exercise weight loss Exercise without weight loss Week WOMEN MEN Weekly weight loss (kg) Week (≈7.5 kg) Weekly weight loss (kg) (≈6 kg) -7 -6 -5 -4 -3 -2 -1 0 1 0 2 4 6 8 10 12 14 0 2 4 6 8 10 12 -8 -7 -6 -5 -4 -3 -2 -1 0 1
Effects of Aerobic Exercise (4 Months) With or Without Weight  Loss on Waist Circumference in Obese Men and Women ,[object Object],[object Object],Change in waist circumference (cm) OBESE MEN OBESE WOMEN No change in BMI No change in BMI Change in waist circumference (cm) Control Weight loss No weight loss Exercise * Significant treatment differences (pre vs. post) compared with control (p<0.05) †   Significant treatment differences (pre vs. post) compared with exercise weight loss (p<0.05) † * * † * Control Weight loss No weight loss Exercise
Influence of Equivalent Diet- or Exercise-Induced Weight Loss on Abdominal Fat (MRI) in Obese Women ,[object Object],Change in abdominal fat (kg) C EWL EWW DWL C EWW DWL EWL Change in abdominal  subcutaneous and visceral fat (kg) Abdominal subcutaneous fat Intra-abdominal (visceral) fat NO DIFFERENCE * Significant treatment differences (pre vs. post) compared with control (p<0.05) †   Significant treatment differences (pre vs. post) compared with diet weight loss (p<0.05) ‡  Significant treatment differences (pre vs. post) compared with exercise weight loss (p<0.05) * * * † * * * * * * † ‡ C: control DWL: diet weight loss (6 kg) EWL: exercise weight loss (6 kg) EWW: exercise without weight loss MRI: magnetic resonance imaging NO DIFFERENCE
Exercise Without Weight Loss is an Effective Strategy for  Obesity Reduction in Men With and Without Type 2 Diabetes (T2D) ,[object Object],* * * Absolute change (kg) Lean Obese T2D Intra-abdominal (visceral) adipose tissue * *  † *  † Relative change (%) Lean Obese T2D * * * * * Balanced diet, no caloric restriction, no weight loss * Significant treatment differences (pre vs. post) within group, p<0.01 †   Significantly greater reduction in intra-abdominal fat by comparison to the lean group, p<0.01   Abdominal subcutaneous adipose tissue
Exercise With or Without Weight Loss on Skeletal Muscle Mass in Obese Men and Women ,[object Object],[object Object],Change in skeletal muscle (kg) C EWL EWW DWL * Significant treatment differences (pre vs. post) compared with control (p<0.05) †   Significant treatment differences (pre vs. post) compared with diet weight loss (p<0.05) * Change in skeletal muscle (kg) C EWL EWW DWL † OBESE MEN OBESE WOMEN C: control DWL: diet weight loss (6 kg) EWL: exercise weight loss (6 kg) EWW: exercise without weight loss MRI: magnetic resonance imaging
Effect of Acute Exercise on Insulin Sensitivity  in Men and Women ,[object Object],Insulin sensitivity (mg/kg/min) Baseline * p=0.05 compared to baseline * 27% Acute  (1 Day)
Proposed Model for the Signalling Pathways Mediating Insulin and Contraction-Induced Skeletal Muscle Glucose Transport ,[object Object],Akt: protein kinase B AMPK: AMP-activated protein kinase AMT: ATP: adenosine monophosphate and a denosine-5'-triphosphate ratio aPKC: atypical protein kinase C AS160: Akt substrate of 160 kDa CaMKII: Ca 2+ /calmodulin-dependent protein kinase II CaMKK: Ca 2+ /calmodulin-dependent protein kinase kinase  GLUT 4: glucose transporter 4 IRS-1/2: insulin receptor substrate 1/2 LBK1: serine/threonine kinase P: phosphorylation PI3K: phosphatidylinositol 3-kinase
The Future of Obesity Reduction: Beyond Weight Loss ,[object Object],Weight change (%) Change in glucose disposal (mg/kg muscle/min) Decrease in OGTT-insulin AUC (UI) Exercise with or without weight loss on glucose metabolism Control +4  to 0 -0.1 to -3 -3.1 to -5 -5.1 to -8 -8.1 to -10 Weight change (%) Control +4  to 0 -0.1 to -3 -3.1 to -5 -5.1 to -8 -8.1 to -10
Obese Elderly: The Merging of Two Epidemic Trends Intra-abdominal (visceral) fat Skeletal muscle Subcutaneous fat  Cardiovascular  disease risk Upper Body Lower Body
Effects of Exercise Modality on Insulin Resistance and Functional Capacity in Aging: A Randomized Controlled Trial ,[object Object],Abdominally obese men and women (age ≈68 years):  6-month  exercise intervention,  without caloric restriction . Random allocation 1. Control  (n=28) 2. Resistance exercise  (n=36) 3. Aerobic exercise  (n=37) 4. Resistance and aerobic  (n=35) Treatment groups
Effects of Exercise Modality on Body Weight and Waist Circumference in Older Men and Women ,[object Object],Percent change (%)  Control Resistance exercise Aerobic exercise Aerobic and resistance exercise Body weight -6 -5 -4 -3 -2 -1 0 1 * Change significantly greater than the control group p<0.05 †   Change significantly greater than the resistance exercise group p<0.05 Waist circumference * *  † * *  † *  †
Effects of Exercise Modality on Intra-Abdominal Fat, Total Fat and Skeletal Muscle in Older Men and Women ,[object Object],Skeletal muscle Abdominal fat Intra-abdominal (visceral) fat Total fat * Percent change (%) *  †   * *  † Control Resistance exercise Aerobic exercise Aerobic and resistance exercise *  ‡ *  ‡ * * * Change significantly greater than the control group p<0.05 †   Change significantly greater than the resistance exercise group p<0.05 ‡   Change significantly greater than the aerobic exercise group p<0.05
Effects of Exercise Modality on Insulin Sensitivity in Older Men and Women ,[object Object],Percent change in insulin sensitivity (%) *  † * Control Resistance exercise Aerobic exercise Resistance and aerobic exercise * Change significantly greater than the control group p<0.05 †   Change significantly greater than the resistance exercise group p<0.05
Principal Finding 150 minutes of weekly exercise  ,[object Object],[object Object],[object Object],[object Object],Balanced diet, exercise, no weight loss Adapted from Davidson LE et al. Arch Intern Med 2009;169:122-31
For Reducing Obesity and Related Comorbidities,  Exercise Without (Minimal) Weight Loss is Not a Failure ,[object Object],Benefits Winner! 0 2 4 6 8 Control Weight loss No weight loss Exercise No change in BMI Waist circumference reduction ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Obese men and women
Rethink   our   Treatment Targets For management of obesity and related health risk,  we must look beyond weight loss as the only indicator of therapeutic/treatment success.
Add Waist Circumference to Routine Allied Health Care ,[object Object],[object Object]
Overview ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Reduction in the Incidence of Type 2 Diabetes with  Lifestyle Intervention or Metformin  ,[object Object],[object Object],[object Object],[object Object],Study year Cumulative incidence of diabetes (%) 14.4% 21.7% 28.8% Placebo Metformin Lifestyle
Exercise on Prescription for Women Aged 40-74 Recruited Through Primary Care: Two-Year Randomized Controlled Trial Objective To increase proportion of participants achieving at least 150 minutes of moderate intensity physical activity at  12 and 24 months. Lawton BA  et al. BMJ 2008;337:a2509
Timeline of Intervention ,[object Object],V: Visit with primary care nurse: brief counselling to increase physical activity (≈30 minutes) T: Telephone-based activity counselling from  exercise specialist  (≈15 minutes) Pragmatic, cost-effective 24 months Outcome measures 9-month intervention: “ Lifestyle script” 6 months V 12 months Outcome measures Baseline T T T T T V All counselling based on motivational interviewing techniques.
Proportion of Participants Achieving at Least 150 minutes of Moderate Intensity Physical Activity at Baseline and 12 and 24 Months ,[object Object],Proportion (%) Intervention Control p<0.001 NO WEIGHT OR WAIST REDUCTION
Determining Optimal Approaches for Weight Maintenance: a Randomized Controlled Trial ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Subjects who  lost ≈5% weight Random allocation Treatment groups
Timeline of Intervention ,[object Object],2 weeks Baseline 24 months 12 months Nurse Intensive 11, 1 on 1 sessions 30 minutes (kinesiologist) 24 months Outcome measures 12 months Outcome measures V T K: Visit with kinesiologist: brief counselling to increase physical activity D: Visit with nutritionist to receive instruction on assigned diet V: Visit with primary care nurse: brief counselling to increase physical activity (≈30 minutes) T: Telephone-based activity counselling from kinesiologist (≈15 minutes) K D V T 10 minutes, every two weeks
Differences at Follow-Up in Body Weight and Waist Circumference of Participants of the Nurse-Support and the Intensive-Support Program ,[object Object]
Change in Body Weight According to Attendance at Counselling Sessions for Weight Loss ,[object Object],[object Object]
To Sustain Adoption of Healthy Behaviours… Self-monitoring and support It may not be what we (interventionist) say, but how we say it  (supportive) ,   and  how often  (short and sweet) .
Opportunity for Management of Obesity… …Reorganize Health Care Teams ,[object Object],[object Object],[object Object],[object Object],[object Object],Primary care tomorrow Nutritionist Kinesiologist Physician Nurse Behavioural consultant Primary care today Physician Nurse
If Physical Activity is the Answer… What is the Problem? A Response, Create Optimal Defaults Increasing physical activity behaviour in today’s  environment poses a challenge…
Optimal Default … “ The challenge is to create better defaults. This will be possible  only when we turn from blaming people for irresponsible  actions to giving the nation what it deserves -- conditions  that make responsible behavior the easy choice.” Kelly Brownell, Yale University,  Rudd Center For Food Policy and Obesity  … Make responsible behaviours the easy choice
Challenges: Creating Optimal Defaults  ,[object Object],[object Object],[object Object],[object Object]
Free Gym!!
Optimal Default… Make Responsible Behaviours the Easy Choice
VIENNA
SUMMARY
Overview ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Add Waist Circumference to Routine Allied Health Care ,[object Object],[object Object]
Measure Cardiorespiratory Fitness and/or Physical Activity Level
Brief Physical Activity Assessment Tool Purpose: To Distinguish Inactive From Regularly Active Patients ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Total score 1 + score 2: ______ Score ≥ 4 = ‘‘Sufficiently’’ active (encourage patient to KEEP IT UP) Score 0–3 = ‘‘Insufficiently’’ active (encourage patient to do MORE)
Importance of Self-Monitoring – Role for Pedometers Accumulate 30-60 minutes per day 3000 to 10,000 extra steps/day
Rethink our Treatment Targets For management of obesity and related health risk,  we must look beyond weight loss as the only indicator of therapeutic/treatment success.
Strategies for Reducing Obesity-Related Diabetes Risk ,[object Object],BMI: body mass index CRF: cardiorespiratory fitness WC: waist circumference No change in BMI No change in WC    CRF No change in BMI    WC    CRF    BMI    WC    CRF    Mortality and   morbidity risk?    Mortality and   morbidity risk?    Mortality and   morbidity risk?
Take Home Messages ,[object Object],[object Object],[object Object]
 

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Physical Activity in the Management of Abdominal Obesity

  • 1. PHYSICAL ACTIVITY IN THE MANAGEMENT OF ABDOMINAL OBESITY Robert Ross, PhD School of Kinesiology and Health Studies, Department of Medicine, Division of Endocrinology and Metabolism Queen’s University Kingston, Ontario, Canada
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  • 6. Add Waist Circumference to Routine Allied Health Care To help identify the high-risk, abdominally obese patient.
  • 7. Health Risk in Adults According to Body Mass Index (BMI) and Waist Circumference
  • 8. Abdominal Obesity and Cardiometabolic Risk Intra-abdominal fat is a strong correlate of cardiometabolic risk Intra-abdominal or visceral fat INSIDE OUTSIDE
  • 9. Waist circumference and intra-abdominal (visceral) fat should be primary targets for strategies designed to reduce obesity and related comorbidities.
  • 10.
  • 11. Question Is it also possible to observe meaningful reduction in waist circumference, intra-abdominal fat and insulin resistance in response to exercise with no change in body weight? Is it possible to observe meaningful reduction in waist circumference, intra-abdominal (visceral) fat and insulin resistance in response to exercise with substantial (>5%) weight loss? YES
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  • 21. Obese Elderly: The Merging of Two Epidemic Trends Intra-abdominal (visceral) fat Skeletal muscle Subcutaneous fat Cardiovascular disease risk Upper Body Lower Body
  • 22.
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  • 28. Rethink our Treatment Targets For management of obesity and related health risk, we must look beyond weight loss as the only indicator of therapeutic/treatment success.
  • 29.
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  • 32. Exercise on Prescription for Women Aged 40-74 Recruited Through Primary Care: Two-Year Randomized Controlled Trial Objective To increase proportion of participants achieving at least 150 minutes of moderate intensity physical activity at 12 and 24 months. Lawton BA et al. BMJ 2008;337:a2509
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  • 39. To Sustain Adoption of Healthy Behaviours… Self-monitoring and support It may not be what we (interventionist) say, but how we say it (supportive) , and how often (short and sweet) .
  • 40.
  • 41. If Physical Activity is the Answer… What is the Problem? A Response, Create Optimal Defaults Increasing physical activity behaviour in today’s environment poses a challenge…
  • 42. Optimal Default … “ The challenge is to create better defaults. This will be possible only when we turn from blaming people for irresponsible actions to giving the nation what it deserves -- conditions that make responsible behavior the easy choice.” Kelly Brownell, Yale University, Rudd Center For Food Policy and Obesity … Make responsible behaviours the easy choice
  • 43.
  • 45. Optimal Default… Make Responsible Behaviours the Easy Choice
  • 48.
  • 49.
  • 50. Measure Cardiorespiratory Fitness and/or Physical Activity Level
  • 51.
  • 52. Importance of Self-Monitoring – Role for Pedometers Accumulate 30-60 minutes per day 3000 to 10,000 extra steps/day
  • 53. Rethink our Treatment Targets For management of obesity and related health risk, we must look beyond weight loss as the only indicator of therapeutic/treatment success.
  • 54.
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  • 56.