Age-adjusted Prevalence of Obesity and Diagnosed Diabetes Among US Adults

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1 Neil Skolnik, M.D. Professor of Family and Community Medicine Sidney Kimmel Medical College Thomas Jefferson University Associate Director Family Medicine Residency Program Abington Jefferson Health 1. Review epidemiology of obesity and diabetes 2. Discuss the evidence linking exercise to health and lower risk of disease 3. Develop a clear concrete approach to advising patients about exercise US Dept of Health and Human Services. Healthy People 2020: Data Search Physical Activity. HealthyPeople.gov website. search /search the data#topic area=3504. Accessed 9/2018

2 Age-adjusted Prevalence of Obesity and Diagnosed Diabetes Among US Adults Obesity (BMI 30 kg/m 2 ) No Data <14.0% 14.0% 17.9% 18.0% 21.9% 22.0% 25.9% > 26.0% Diabetes No Data <4.5% 4.5% 5.9% 6.0% 7.4% 7.5% 8.9% >9.0% CDC s Division of Diabetes Translation. United States Surveillance System available at

3 Why What Where When Who

4 Immediate Reduction in anxiety, blood pressure, insulin resistance Improved cognitive function and sleep Long term Increased cardiorespiratory fitness and muscular strength Decreased incidence of: Cancer, Diabetes, Depression, Erectile dysfunction, Osteoporosis, Cardiovascular Disease, All cause Mortality Piercy KL, Troiano RP, Ballard RM, et al. The Physical Activity Guidelines for Americans. JAMA.2018;320(19): doi: /jama Piercy KL, Troiano RP, Ballard RM, et al. The Physical Activity Guidelines for Americans. JAMA.2018;320(19): doi: /jama Retrospective Case Control Trial (55 64 y.o ): 1123 women with Breast Ca 904 women without Exercise vs. non exercise Odds Ratio 0.55 Carpenter CL, et al. Br J Cancer. 1999;80(11):

5 Case Control study: 1000 cases and 1074 controls For the group with diabetes as a whole, post menopausal women had a 2.7 x risk of breast cancer. Torres Mejía G, et al. Diabetes Care. 2012;35(12): Torres MejíaG, et al. Diabetes Care. 2012;35(12): Physical activity was estimated using a 7 day recall questionnaire that estimated an individual s time spent performing physical activities Prospective Cohort Studies 19 studies Males High levels vs low levels of Occupational activity RR Recreational activity RR 0.78 Women Occupational activity no significant difference Recreational activity RR 0.71 Prospective, observational cohort study of 13,949 community dwelling men who had a baseline fitness examination Cardiorespiratory fitness levels were assessed between 1971 and 2009, and incident lung, prostate, and colorectal cancer using Medicare claims data from 1999 to 2009 Samad AK, et. Al. Colorectal Dis. 2005;7(3): Lakoski SG, et al. JAMA oncology. 2015;1(2):

6 High Cardiorespiratory fitness is related to a decreased risk of Lung cancer (Risk Ratio.4) and Colorectal cancer (Risk Ratio 0.6) One third of the more than 572,000 cancer deaths that occur in the United States each year can be attributed to diet and physical activity habits. Physical activity may reduce the risk of cancers of the breast, colon, endometrium, advanced prostate cancer, and possibly, pancreatic cancer. Lakoski SG, et. Al. JAMA oncology. 2015;1(2): Kushi LH, et. Al. CA Cancer J Clin. 2012;62(1):30 67.

7 43 year old woman presents for follow up of routine blood work after annual physical exam. PMH none PE WNL except BMI 32.5 Labs A1c 6.1 Approach? 3234 persons with Pre diabetes (elevated fasting and postload plasma glucose) randomized to: Placebo Metformin (850 mg twice daily) Lifestyle modification program DPPRG. Reduction in the Incidence of Type 2 Diabetes with Lifestyle Intervention or Metformin. NEJM, 2002;346(6): Lifestyle had greatest improvement in physical conditioning and greatest decrease in weight. Reduction in incidence of diabetes compared to usual care group: Metformin 31% Lifestyle Intervention 58% DPPRG. Reduction in the Incidence of Type 2 Diabetes with Lifestyle Intervention or Metformin. NEJM, 2002;346(6): DPPRG. Reduction in the Incidence of Type 2 Diabetes with Lifestyle Intervention or Metformin. NEJM, 2002;346(6):

8 Diabetes incidence rates during the follow up were similar between all groups. In the 10 years since DPP randomization DM incidence reduced by 34% in the lifestyle group and 18% in the metformin group com Prevention or delay of diabetes with lifestyle intervention or metformin can persist for at least 10 years compared with placebo. Cumulative incidence of diabetes remained lowest in the lifestyle group. Incidence rates of diabetes during the three study DPPRG. Lancet November 14; 374(9702): Works delivered at the YMCA Works broadly at CDC organized programs (1) Am J Public Health 2008;35: (2) Diabetes Care 2017 Oct; 40 (10): (3) type2/preventing.html Close relation to number of sessions attended and both physical activity and weight loss. We can encourage patients to comply with the program. CDC Registry: Diabetes Care 2017 Oct; 40(10):

9 53 studies Compared with usual care, diet and physical activity promotion programs reduced type 2 diabetes incidence (RR, 0.59) decreased body weight (net change, 2.2%) fasting blood glucose level and improved other cardiometabolic risk factors More intensive programs were more effective. Meta analysis of 17 studies of the effect of exercise on Allcause Mortality (ACM) and CV disease in patients with diabetes. Highest Physical Activity compared to lowest Physical activity group, Relative Risk of: ACM 0.61 ( ) CVD 0.71 ( ) Balk EM, et.al. Ann Intern Med ;163: doi: /M Kodama S, Tanaka S, HeianzaY, et al. Association Between Physical Activity and Risk of All Cause Mortality and Cardiovascular Disease in Patients With Diabetes. A meta analysis. 2013;36(2): Observational trial of 53,587 Norwegian men and women Compared hazard ratio of CV disease in physically inactive people without diabetes to both physically active people without diabetes as well as both physically inactive and active people with diabetes CV Mortality (Haz Ratio) CV Mortality (Haz Ratio) Physically active: >3 hrs light activity per week 0 Inactive with DM Inactive w/o DM Active w DM Active w/o DM Moe B, Eilertsen E, Nilsen TIL. The Combined Effect of Leisure Time Physical Activity and Diabetes on Cardiovascular Mortality. The Nord Trøndelag Health (HUNT) cohort study, Norway. 2013;36(3): Moe B, Eilertsen E, Nilsen TIL. The Combined Effect of Leisure Time Physical Activity and Diabetes on Cardiovascular Mortality. The Nord Trøndelag Health (HUNT) cohort study, Norway. 2013;36(3):

10 391 RCTs, 197 of which evaluated exercise interventions (10,461 participants) and 194 evaluated antihypertensive medications (29,281 participants) In patients with hypertension, exercise and antihypertensives yielded similar SBP reductions. Naci H. Br J Sports Med Epub doi: / bjsports Epidemiology depression is more common in those with low levels of physical activity. Meta Analysis of 13 studies lasting from 4 16 weeks: Exercise leads to a 31% better odds of depression remission by end of study (1) Exercise for Depression. Cochrane Database of Sytematic Reviews 2009, Issue 3, Art. No.: CD DOI: / CD pub4 (2) Krogh J, Nordentoft M, Sterne JA, Lawlor DA. The effect of exercise in clinically depressed adults: systematic review and meta analysis of randomized controlled trials. J Clin Psychiatry. 2011;72(4):

11 Twenty three trials comparing exercise with no treatment or control intervention. Pooled data indicated a large clinical effect. In the three trials with adequate allocation concealment the pooled result was 0.42 indicating a moderate effect. Effect apparent for both aerobic and resistance exercise Cognitive therapy and exercise performed about the same. Ninety articles involving 10,534 sedentary patients with a chronic illness primarily CV disease, chronic pain, fibromyalgia, obesity, cancer, Alzheimer s Disease, and COPD Exercise training significantly reduced depressive symptoms Similar to the effect of pharmacotherapy on depressive symptoms among patients with strokeand fibromyalgia. Exercise for Depression. Cochrane Database of Sytematic Reviews 2009, Issue 3, Art. No.: CD DOI: / CD pub4 Herring MP, PuetzTW, O'Connor PJ, Dishman RK. Effect of exercise training on depressive symptoms among patients with a chronic illness: a systematic review and meta analysis of randomized controlled trials. Arch Intern Med. 2012;172(2): Anxiety related disorders have a prevalence of approximately 25 35% lower among those reporting physical activity than those who do not. (1) Goodwin RD. Association between physical activity and mental disorders among adults in the United States. Prev Med. 2003;36(6): (2) Asmundson GJ, Fetzner MG, Deboer LB, Powers MB, Otto MW, Smits JA. Let's get physical: a contemporary review of the anxiolytic effects of exercise for anxiety and its disorders. Depress Anxiety. 2013;30(4):

12 Moderate and vigorous intensity PA is associated with normal erectile function and lower risk of ED. The protective effect of PA also applies to men with obesity, HTN, and metabolic syndrome Exercise improves ED (six trials). Exercise decreases the risk of osteoporosis and falls (1) J Urol 2006; 1761: (2)Am J Med 2007;1202: (3)Sex Med 2018;6:75e89. (1) Bull World Health Organ vol.81 no.11 Genebra Nov (2) Sports Medicine 1998; 6: Randomized trial of aerobic exercise (n=43) In patients with moderate to severe asthma aerobic training: Decreases bronchial hyperresponsiveness Decreases frequency of exacerbations (0.6 vs 1.5 exacerbations/patient; p=0.021) Improved quality of life (ACQ 6) Of 1415 consecutive patients with AF, 825 had BMI 27 kg/m2 and were offered weight management. After screening for exclusion criteria, 355 were included in this analysis. Weight loss >10% resulted in a six fold (p<0.001) greater probability of arrhythmia free survival compared to other two groups. França Pinto A, Mendes FAR, de CarvalhoPinto RM, et al. Thorax 2015;70: (1) (LEGACY Study), Journal of the American College of Cardiology (2015), doi: /j.jacc (2) Craig T, Wann LS, Calkins H, et al AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation. Circulation.0(0):CIR

13 6 trials, 305 participants Studied effect of structured exercise programs over weeks Outcomes: Reduced time to fall asleep, improved global sleep quality score. No change in sleep duration Aerobic exercise training reduces the severity of OSA, and this effect has been observed with little or no changes in body weight. This effect corresponded to about 42% reduction in apnea severity compared to baseline along with significant improvements in cardiorespiratory fitness, daytime sleepiness, and sleep efficiency The difference between exercise training and CPAP was nonsignificant Yang PY, et. Al. J Physiother. 2012;58(3): (1) Lung 2014;192(1):175e84; (2) Sleep 2011;34(12):1631e40; (3) Sleep Medicine 30 (2017) 7 14 Population: 138 participants with mild cognitive dysfunction Randomized to exercise (150 min/wk) vs. usual care Results: intervention group improved 0.26 points vs. usual care deteriorated 1.04 points on the ADAS Cog (70 point scale) at the end of the intervention (6m) At 18 m a non sig improvement was sustained (0.73 vs 0.04) 6104 consecutive veteran patients (mean age: 59 years) referred for treadmill exercise testing followed for 10 years Relative risk of the combined end point of dementia, Alzheimer disease, and cognitive impairment Compared to those with Exercise Capacity (METs) >12: 9 12 METS: METS : 2.80 <6 METS : 4.42 Lautenschlager NT, et al. Effect of physical activity on cognitive function in older adults at risk for Alzheimer disease: a randomized trial. JAMA. 2008;300(9): Mayo Clin Proc. 2017;92(2):

14 Background: Reduced mobility is common in older adults It is an independent risk factor for morbidity, hospitalization, disability, and mortality. Methods Multicenter, randomized trial x 2.6 years Men and women aged 70 to 89 years who had physical limitations, but were able to walk 400 m. Structured, moderate intensity physical activity program (n = 818) Pahor M, et al. JAMA. 2014;311(23): % 20% 15% 10% 5% 0% Pahor M, et al. JAMA. 2014;311(23): Persistent mobility disability 20% 15% Physical Activity Health Ed HR, 0.72; P = % 38% 37% 36% 35% 34% 33% 32% 31% 30% 29% Pahor M, et al. JAMA. 2014;311(23): Major mobility disability or death 38% 32% Physical Activity Health Ed HR, 0.82; P =.02 Randomized trial of the effect of 50%, 100%, and 150% of the physical activity recommendation on QOL over 6 months. 430 sedentary postmenopausal women a non exercise control group (n=92) or 1 of 3 exercise groups: exercise energy expenditure of 4 (n=147), 8 (n=96), or 12 (n=95) kilocalories per kilogram of body weight per week. Martin CK, et al. Arch Intern Med. 2009;169(3):

15 Strong relationship between level of exercise in intervention and: Physical functioning Mental Health Emotional Well being Body Pain Social Functioning General Health Vitality Martin CK, et al. Arch Intern Med. 2009;169(3): consecutive men referred for treadmill exercise testing for clinical reasons during a mean (±SD) of 6 ±4 years of follow up For co morbidities of Hypertension, COPD, Diabetes, Smoking, BMI >30, Total Cholesterol >220 mg/dl, relative risk of death over 7.5 years: >8 MET MET <5 MET Thirty three studies (102,980 participants) included in metaanalysis. Cardiorespiratory fitness (CRF) was assessed by an exercise stress test and the association of CRF with all cause mortality and with CVD was evaluated Myers J, et al. NEJM. 2002;346(11): Kodama S, Saito K, Tanaka S, et al. JAMA. 2009;301(19):

16 Compared with participants with intermediate CRF, those with low CRF had 40% higher all cause mortality and 47% higher CHD/CVD event rate. Compared with participants with high CRF, those with low CRF had a 70% higher age adjusted all cause mortality and 56% higher CHD/CVD event rate. Should we add this into our risk calculations? Cohort study follow up of 11,049 men who had clinical exam at the Cooper Institute in Dallas, Texas, before 1990 and followed until: CVD death, Non CVD death, Attainment of age 90 years 281,469 person years of follow up, median follow up 25.3 years, 1,106 CVD deaths * Kodama S, et. al. JAMA. 2009;301(19): Jarett D. Berry,et al. Journal of the American College of Cardiology Apr 2011, 57 (15) * 40% 30% 20% 10% 0% Lifetime Risk of CV Death at 45 years old 34% Low Fitness 15% High Fitness 40% 30% 20% 10% 0% Lifetime Risk of CV Death at 55 years old 34% Low Fitness 15% High Fitness The presence of a higher fitness level in mid life attenuated substantially the risk from traditional risk factors (elevated cholesterol, hypertension, diabetes, or current smoking status) Those who have risk factors but are fit have about the same mortality of those who who do not have risk factors, but are not fit. Differences in fitness levels (low fitness vs. high fitness) were associated with marked differences in the lifetime risks for CVD death at each index age Journal of the American College of Cardiology. 2011;57: 1604 Jarett D. Berry,et al.journal of the American College of Cardiology Apr 2011, 57 (15)

17 6,962 patients A simple question about do you exercise three times a week enough to experience a fast heart beat, sweat or shortness of breath predicts mortality over 10 years Age adjusted 36% higher risk of mortality amount those who do not exercise. Myers. The American Journal of Medicine (2015) 128, baseline: 7925 healthy men and 7977 healthy women of the Finnish Twin Cohort aged 25 to 64 years Questionnaire on physical activity habits and known predictors of mortality. Among Twins there was lower mortality among those who exercised comparted to their non exercising twin. Prospective study of 9777 men, with two clinical examinations (mean interval between examinations, 4.9 years) to assess change or lack of change in physical fitness Main Outcome Measures All cause(n=223) and cardiovascular disease (n=87) mortality. Those who where unfit and remained unfit had about a 20% higher mortality compared to those where were unfit and became fit. Kujala UM, Kaprio J, Sarna S, Koskenvuo M. Relationship of leisure time physical activity and mortality: the Finnish twin cohort. JAMA. 1998;279(6): Blair SN, et al. Changes in physical fitness and all cause mortality. A prospective study of healthy and unhealthy men. JAMA. 1995;273(14):

18 JAMA Network Open. 2019;2(3):e Hazard Ratio for All Cause Mortality 1 Consistently Inactive Maint. High LTPA Increase LTPA (start low, increase) Adults who were less active throughout most of the adult life course but increased LTPA in later adulthood (40 61 years of age) also had lower risk CVD related (HR, 0.57)and cancer related (HR, 0.84) mortality. Health is being lost from childhood through young adulthood and that the major reasons are adverse health behaviors related to diet, physical activity, healthy weight maintenance, and smoking. The elimination of these health risk behaviors would make it possible to prevent at least 80% of heart disease, stroke, and type 2 diabetes mellitus, and even 40% of cancers. Spring B, Ockene Judith K, Gidding Samuel S, et al. Better Population Health Through Behavior Change in Adults. Circulation. 2013;128(19): Spring B, Ockene Judith K, Gidding Samuel S, et al. Better Population Health Through Behavior Change in Adults. Circulation. 2013;128(19):

19 Comprehensive review of the evidence on whether primary care counseling for healthful diet and physical activity modify outcomes in patients with CV risk factors. Interventions involved an average of 5 to 16 contacts over 9 to 12 months depending on their intensity IT WORKS! LeFevre ML, et al. Ann Intern Med. 2014;161(8): LeFevre ML, et al. Ann Intern Med. 2014;161(8): Strong evidence demonstrates that regular physical activity has health benefits for everyone, regardless of age, sex, race, ethnicity, or body size. Being physically active is one of the best investments individuals and communities can make in their health and welfare. Piercy KL, Troiano RP, Ballard RM, et al. The Physical Activity Guidelines for Americans. JAMA.2018;320(19): doi: /jama

20 Give Half hearted Advice Do Not Describe a Clear Plan Do Not Arrange for Follow up Assume Failure Primary Goal Develop Exercise Habit Next set Concrete Steps Short Term Goals Long term Goals Team Approach Personal Trainers Anticipatory Guidance Anticipate Hurdles Follow up Why What Where When Who Why

21 Provide Information Provide options from which the patient can choose Meds vs. Diet/exercise What type of Exercise? What level of exertion? How long, how often? Intensity can be described in two ways: absolute intensity and relative intensity Absolute: Expressed in METS 1 MET is equivalent to the resting metabolic rate or the energy expenditure while awake and sitting quietly Moderate 3 6 METS walking briskly; raking the yard Vigorous >6 METS jogging or running; strenuous fitness class Heart Rate 60 80% of Max heart rate (220 age). Talk Test Moderate intensity aerobic activity: can talk, but not sing, during the activity. Vigorous intensity activity: generally cannot say more than a few words without pausing for a breath. JAMA. 2018;320(19): JAMA. 2018;320(19):

22 Adults (18 64) At least 150 minutes to 300 minutes of moderateintensity, or 75 minutes to 150 minutes of vigorousintensity aerobic physical activity a week Muscle strengthening activities of all major muscle groups 2 or more days per week Older adults (65+) Same as adult except Addition of balance exercises If they cannot do 150 minutes of moderate intensity aerobic activity a week they should be as physically active as their abilities and conditions allow. Where are you going to exercise?

23 What days? What time of day? Who is your behavioral coach? A STORY Learning Point: Our own attitudes influence the behavior of our patients. Exercise has a vast amount of beneficial effects on the body 150 minutes of moderate intensity exercise Add strength and balance exercises if over 65 Be Concrete Why, What, Where, When and Who