st Century John Saxton Professor of Clinical Exercise Physiology University of East Anglia The World Health Organisation predicts that chronic conditions will be the leading cause of disability by 2020 and that if not successfully managed will become the most expensive problem for health ca ID: 790433
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Slide1
Physical activity: an old-fashioned remedy for the health challenges of the 21
st
Century?
John Saxton
Professor of Clinical Exercise PhysiologyUniversity of East Anglia
Slide2The World Health Organisation predicts that chronic conditions will be the leading cause of disability by 2020 and that, if not successfully managed, will become the most expensive problem for health care systems
Slide3Slide4In England, 15.4 million people are currently living with a chronic condition
It is estimated that up to three-quarters of those over 75 y are suffering from a chronic condition, and this figure continues to rise
By 2030, the estimate is that the incidence of chronic disease in the over 65s will more than double
The treatment of chronic conditions accounts for 70% of total health and social care costs
Slide5The ageing population
Slide6By 2034, it is projected that:
nearly a quarter (23%) of the UK population will be aged ≥65 y (from 16% in 2008)
5% of the UK population will be ≥85 y
76.8
80.4
81.6
66.7
68.8
64.3
0
10
20
30
40
50
60
70
80
90
1981
2001
2006-8
LE
HLE
70.9
75.7
77.4
64.4
67
62.5
0
10
20
30
40
50
60
70
80
90
1981
2001
2006-8
LE
HLE
Women Men
Life expectancy (LE)
versus
Healthy Life Expectancy (HLE)
Office for National Statistics 2011
Age (years)
Age (years)
Slide7The evolution of man and lifestyle behaviours
from Homo erectus to Homo sapiens…
Slide8The world of today is not the environment we evolved in…
Our lifestyles have been transformed from that of wandering hunter-gatherers to sedentary consumers of more than we need to survive
‘Homo sedentarius’
‘Homo obesus’
from Homo erectus to Homo sapiens…
Slide9Mean number of hours per working day in occupational activities, by sex
Self-reported sedentary time
Health Survey for England 2008, Volume 1: Physical activity and fitness
Slide10Prevalence of overweight and obesity
Health Survey for England 2009, Volume 1: Health and Lifestyles
Slide11How important is the link between physical inactivity and chronic disease?
Slide12As early as the ninth century B.C., the ancient Indian system of medicine (Ayurveda) recommended exercise and massage for the treatment of rheumatism
Greek philosopher Hippocrates (‘the father of medicine’) acknowledged the virtues of exercise for physical and mental health in the 4th century B.C.
Slide13Physical inactivity is estimated to be the principal cause of ~30% of the ischaemic heart disease burden, ~27% of the diabetes burden and ~21-25% of the breast and colon cancer burdens (WHO 2009).
Worldwide, approximately 3.2 million deaths (6% of all deaths) each year are attributable to insufficient physical activity (WHO 2010).
World Health Organisation statistics
Slide14WHO 2009
Slide15Evidence for the health benefits of exercise
Slide16Ralph S Paffenbarger Jr 1922 - 2007
Jerry N Morris 1910 - 2009
Steven N Blair 1939 -
Bus drivers in their 40’s were nearly five times more likely to develop ischaemic heart disease than age-matched conductors
(Morris et al. 1966; Lancet 2; 553-559). 40% reduced risk of fatal heart attack and a 50% reduction in non-fatal coronary events among British male civil servants who participated in vigorous exercise requiring peaks of energy expenditure (
Morris et al. 1980; Lancet 2: 1207-1210
).
28% reduced risk of all-cause mortality
among USA college alumni reporting a weekly exercise energy expenditure of
2000 kcal.week
-1
(
Paffenbarger et al. 1986; NEJM 314; 605-613
).
7.9% decrease in all cause mortality
for every 1 min improvement in treadmill walking time (roughly equivalent to 1 MET increase in aerobic exercise capacity) among men attending medical check-ups at the Cooper Clinic in Dallas USA (Blair et al. 1995; JAMA 273; 1093-1098).
Slide17AICR/WCRF Expert Report 2007
Slide18How much exercise is needed for health and fitness?
Slide19WHO Global Recommendations on Physical Activity for Health (2010)
150 minutes of moderate-intensity aerobic physical activity or 75 minutes of vigorous intensity aerobic physical activity throughout the week, or an equivalent combination of the two.
For additional health benefits, aim to increase this to 300 minutes of moderate aerobic physical activity or 150 minutes of vigorous-intensity aerobic physical activity per week or an equivalent combination of the two.
Aerobic activity should be performed in bouts of at least 10 minutes duration.Muscle strengthening exercises (involving major muscle groups) on 2 or more days per week.
Limit the amount of time spent in sedentary activities
Slide20Objective physical activity levels
Health Survey for England 2008, Volume 1: Physical activity and fitness
Slide21Waiting to take the escalator
Environmental influences on physical activity!!
Slide22“Whenever I feel like exercise, I lie down until the feeling passes”
Behavioural influences on physical activity!!
Slide23How can we get people to exercise at the right levels and in the right way to optimise the health benefits?
Slide24The role of exercise in ameliorating the impact of chronic disease, improving quality of life and survival
Exercise in the management of long-term conditions
Slide25Health-related
Quality of life
&
Disease-free survival
Morphological
(Body composition)
Cardio-respiratory
Metabolic
Motor
Immunological
Molecular
Muscular
Depression
Anxiety
Stress
Self-esteemCognitive functionMood statesSense of controlPerceived fatiguePerceived ability to cope PerceivedPhysical attractiveness Social integrationEnjoyment of lifePhysiologicalPsychosocial
Slide26Can exercise training counteract the adverse physiological and psychological consequences of disease and its treatments?
Function; quality of life; disease-free survivalIn those with long-term conditions, what is the role of exercise in disease modification? How does exercise interact with drug treatments? Can exercise counteract the side-effects of drug treatments?
Why do some patients respond/adapt differently to exercise training?What are the contra-indications to exercise in different clinical groups?
Key research questions:
Slide27Where exercise has proven benefits to a clinical group – how can it be optimised?
Slide28F-I-T-T
PRINCIPLE
TYPE
FREQUENCY
TIME
INTENSITY
Slide29Vignettes –
the application of exercise science to the management of long-term conditions
Optimising exercise rehabilitation in terms of engagement and health benefits in peripheral arterial disease
Impact of exercise on quality of life and disease-free survival after cancer
Exercise and symptoms of clinical fatigue in multiple sclerosis
Slide30Peripheral arterial disease
(intermittent claudication)
Slide31Affected arteries of the lower limb
External iliac artery
Femoral artery
Popliteal arteryPosterior tibial artery
Anterior tibial artery
Dorsalis pedis
(palpation point)
Aortic and iliac arteries
30%
Femoral and popliteal arteries
80-90%
Tibial and peroneal arteries
40-50%
Slide32TREATMENT STRATEGIES FOR IC
EXERCISE THERAPY
PHARMACOLOGICAL TREATMENTSCV RISK FACTOR MODIFICATION
SURGICAL INTERVENTIONS“Stop smoking and keep walking”
Slide33A significant proportion of patients do not engage in walking exercise!!
Problem!
Slide34Leg cranking exercise
Arm cranking exercise
Alternative exercise rehabilitation strategies - rationale
A large proportion (~ 35%) of patients exceed their leg-cycling aerobic exercise tolerance during arm-cranking exercise
Less exercise pain during arm-cranking, despite similar perceived exertion and higher blood lactate at maximal exercise toleranceZwierska et al. (2006); EJVES
Slide35Arm-cranking exercise trials
Slide36Slide37NIRS time to minimum StO
2 was increased after arm-cranking exercise training
Pre
PostCalf muscle haemoglobin saturation during walking (NIRS)
Slide38Chi square analysis showed that the proportion of patients in the arm-cranking group with a favourable
hs-CRP profile (defined as < 1.72 mg.l-1) was higher than in the control group at the 24-week time-point (50% vs 23%, respectively;
P < 0.05).
Evidence of a reduction in systemic inflammation after arm-crank trainingCirculating hs-CRPSaxton et al. (2008); EJVES
Slide39Impact on exercise pain tolerance
Zwierska I et al. (2005).
J Vasc Surg
42:1122-30.
Slide40Central cardiovascular adaptations?
Blood rheology (changes in viscosity)?
Exercise pain threshold/tolerance?Improved blood flow/distribution linked to improved ability of lower limb arteries to dilate during exercise
Mechanisms?
Slide41Nordic pole walking (NPW) study
To investigate whether the use of Nordic poles leads to an improvement in common parameters of walking performance in patients with intermittent claudication
To compare the cardiopulmonary responses and level of leg-pain evoked by NPW with those evoked by normal walking exercise in this patient group
Slide42Experimental set-up and Methods
Methods
N = 20 patients with intermittent claudication recruited from SVIPatients were familiarised with the NPW technique, allowed ample practice time, performed “dummy run”
Two treadmill walks: 3.2 km.h-1 @ 4% gradient in random orderWide belt H-P-Cosmos Saturn Treadmill
Slide43During NPW:
The level of claudication pain at MWD was less despite higher oxygen consumption
For 9/20 patients (45%), the NPW test was terminated for reasons other than claudication pain (e.g. breathlessness/ breathing hard, mouth dry, very tired, exhausted), versus only 1 in the normal walking condition
These results suggest that NPW could be a useful ergogenic aid for improving the cardiopulmonary stimulus to exercise rehabilitation in claudicants
Slide44Cancer survivorship
Slide45There are over 200 different types of cancer
Slide46Slide47Pre-diagnosis
Treatment / surveillance
Recovery / rehabilitation
End of life
Lifestyle behaviours influencing QoL / disease-free survival
Cancer survivorship
Lifestyle behaviours influencing risk
Lifestyle behaviours influencing QoL
Cancer diagnosis
Time-line
Disease recurrence /
Second primary tumour
Lifestyle behaviours influencing treatment outcome / QoL
Stages of the cancer experience
Treatment cycle
Slide4890
80
70
60
50
40
30
20
10
0
Holmes
et al.
(2005)
(Overall mortality)
9-14.9 MET-h/week moderate intensity PA
Pierce et al. (2007)(Overall mortality)25 MET-h/week total recreational PAHolick et al. (2008)(Overall mortality)4-10.2 MET-h/week moderate intensity PAIrwin et al. (2008)(Overall mortality)150 min per week moderate intensity PAMeyerhardt et al. (2006a)(Disease recurrence or death)18-26.9 MET-h/week total recreational PAHolmes et al. (2005)(Breast cancer mortality)9-14.9 MET-h/week moderate intensity PAHolick et al. (2008)(Breast cancer mortality)4-10.2 MET-h/week moderate intensity PAMeyerhardt et al. (2006b)(Colorectal cancer mortality)18 MET-h/week total recreational PA% Risk reductionBreast cancer studiesColorectal cancer studies
Slide4990
80
70
60
50
40
30
20
10
0
Kenfield
et al.
(2011)
(Overall mortality)
≥ 90 min/week normal/brisk pace walking
Richman et al. (2011)(Prostate cancer progression)≥ 3 h/week brisk walkingKenfield et al. (2011)(Prostate cancer mortality)≥ 3 h/week vigorous activity% Risk reductionProstate cancer studies
Slide50Weight gain is a problem for breast cancer patients
The majority of women gain weight and % body fat between 1-3 years post-diagnosis
(Irwin et al. 2005; JCO 23, 774-782)
Mechanisms of weight gain?Chemotherapy / endocrine therapyReduction in lean body mass and resting energy expenditureReduction in physical activity due to fatigueIncreased food ingestion – linked to coping mechanisms / treatment-related appetite
Slide51Being overweight or obese is negatively associated with postmenopausal breast cancer risk and survival
Obesity is associated with later stage at diagnosisRegardless of weight at diagnosis, evidence that every 5 kg increase in body weight confers a 14% increased risk of all cause mortality
(Reviewed in Hede et al. 2008; JNCI 100, 298-299) 24% improvement in relapse-free survival evoked by diet-induced weight loss within a year of diagnosis vs controls who gained weight
(Chlebowski et al. 2006; JNCI 98, 1767-1776)
Slide52Randomised controlled trial:
The effects of a combined Diet and
Exercise intervention on Biomarkers associated with disease R
ecurrence After breast cancer treatment: The Sheffield DEBRA trial.
Slide53Patients
90 post-menopausal women with a BMI > 25 kg/m2 who completed their breast cancer treatment 3-18 months previously randomised to lifestyle intervention or usual care control group
Intervention – 6 months3 supervised exercise sessions per week comprising 30 min of moderate intensity aerobic exercise (treadmill walking, stepping, cycling)
Individualised healthy eating plan with the aim of inducing a steady weight loss of up to 0.5 kg each week
Slide54N=47
N=43
Intervention
groupControlgroupChanges in aerobic fitnessml·kg
-1·min-1**
Slide55**
**
**
*****
Slide56Depression and quality of life
Intervention Group
Control Group
Pre Post Pre Post
Pre Post Pre Post**
**
Slide57N=42
N=48
Weight loss ≥1kg versus <1kg
Slide58Clinical
Slide59Fatigue in clinical populations
Disease processes that limit exercise tolerance and become apparent during physical exertion
Cardiovascular disease
Cardiac disorders
Pulmonary disease
Anaemia/blood disorders
Musculoskeletal disorders
Metabolic disorders
Hormonal disorders
Infectious diseases
Autonomic disorders
Sleep disorders
Slide60“Low energy fatigue”
Disease process
Drug treatments
Pain
Poor sleep
Stress
Low self-efficacy
Depression
Slide61Exhaustion
Lethargy
Languidness
LanguorLassitude
TirednessListlessness
Weakness
Weariness
Anergia
Asthenia
Low energy
Debility
Lacking vigour
Multi-dimensional and complex
Not caused by exertion and does not improve with rest
Subjective symptom
Slide62... lack of interest, energy or spirit
... lack of physical or mental energy... disinclined to exert effort
... loss of interest... mental lethargy
... sluggish and indifferent... drowsy and dull... apathetic... excessive tiredness/urge to sleep
Extreme and persistent tiredness, weakness or exhaustion – mental, physical or both
Slide63… to sum up
Slide64Physical activity: is it an old-fashioned remedy for the health challenges of the 21
st
Century?
Slide65Slide66“Those who think they have not time for bodily exercise will sooner or later have to find time for illness”
Edward Stanley, Earl of Derby 1826-1893, British Statesman. The Conduct of Life, address at Liverpool College, 20 December 1873.
Slide67The End