6/5/2014. Exercise and Metabolic Management DECLINE IN DEATHS. Regular exercise has health benefits for individuals of every weight

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1 Exercise and Metabolic Management Theodore Feldman, MD,FACC,FACP Medical Director, Center for Prevention and Wellness, Baptist Health Medical Director, South Miami Heart Center Heartwell LLP Clinical Associate Professor of Medicine FIU Wertheim College of Medicine Disclosures I have no relevant commercial relationships to disclose. Basics of Exercise & Weight: Not Rocket Science Regular exercise has health benefits for individuals of every weight Exercise can contribute to weight loss Exercise appears to be very important in weight loss maintenance DECLINE IN DEATHS 1

2 Brief Review of Aerobic Exercise & Health Harvard Alumni Study (1985) Mortality Amount of physical activity Prevalence of Overweight Among U.S. Children and Adolescents (Aged 2 19 Years) National Health and Nutrition Examination Surveys (NHANES) 2% 15% 1% 5% % Non-Hispanic whites Non-Hispanic blacks Mexican Americans 2

3 AMERICANS AT INCREASED CAD RISK Exercise and Chronic Diseases Regular exercise reduces risk of or benefits: atherosclerosis and coronary heart disease TC, LDL-C, HDL-C, TG, heart strength Exercise and Chronic Diseases Regular exercise reduces risk of or benefits: atherosclerosis and coronary heart disease TC, LDL-C, HDL-C, TG hypertension BP in hypertensive (but doesn t normalize) colon and breast cancer diabetes mellitus exercise need for insulin obesity energy expenditure 3

4 Does Changing Cardiorespiratory Fitness Reduce Mortality Risk? Aerobics Center Longitudinal Study Design 197 More than 8, patients 25 Cooper Clinic examinations--including history and physical exam, clinical tests, body composition, EBT, and CRF Mortality surveillance to 23 More than 4 deaths Mail-back surveys for case finding and monitoring habits and other characteristics CVD Mortality Rates by Fitness: Aerobic Center Longitudinal Study (ACLS) 1, years Low Moderate High Deaths per person-y Women Men Blair SN et al. JAMA 1989;262:

5 rate/1, Age adj death r PY All-Cause Death Rates by CRF Categories 312 Women and Men ACLS Women Men Low Moderate High Blair SN. JAMA 1989 Age-Adjusted Death Rates by Fitness Change Groups, Men, ACLS Age-adjusted Death Rates/1, Man-years Fitness CVD All-cause Groups Never fit Improvers Always fit 14 4 Blair SN et al. JAMA 1995; 273:193-8 Fitness and All-Cause Mortality, ACLS Men, Adjusted Death Rate per 1, PY % Upper Limit Expected Adjusted Expected Relation Death Rate Relation 95% Lower Limit GXT Test Performance (minutes) 5

6 Fitness and All-Cause Mortality, ACLS Men, Adjusted Death Rate per 1, PY % Upper Limit Expected Adjusted Relation Death Rate 95% Lower Limit GXT Test Performance (minutes) Fitness and Age in Women 22 Peak VO2 (ml/min) Age Cardiorespiratory Fitness and All-Cause Mortality, Women and Men 6 Years of Age 46 women and men All-Cause death rates/1, PY 6 years died during ~14 years of follow-up 4 35 Low ~25% were women 3 25 High Death rates adjusted 2 for age, sex, and 15 exam year Age Groups Sui M et al. JAGS 27. Moderate 6

7 BODY CHANGES, DIET, AND EXERCISE Mortality risk within each fitness category for hypertensive individuals with and without additional risk factors. *Different from the very-low fitness with no risk factors group (referent). Different from the low-fitness with risk factors group. Kokkinos P, and Myers J Circulation. 21;122: Copyright American Heart Association, Inc. All rights reserved. Exercise capacity and relative risk of all-cause mortality in individuals with type 2 diabetes mellitus according to MET levels achieved. Kokkinos P, and Myers J Circulation. 21;122: Copyright American Heart Association, Inc. All rights reserved. 7

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9 Is the loss of farming jobs driving the U.S. adult obesity epidemic? Farming Jobs in US rm Based Jobs % of Employed in Far Church et al, PLoS ONE, May 211 Goods Producing Jobs: Manufacturing, Construction & Mining/Logging % Manufacturing 5. Construction. Mining/Logging Year Church et al, PLoS ONE, May 211 9

10 Jobs in U.S. Over Last 5 Years Service Jobs % Goods Producing Jobs. Agricultural Jobs Year Church et al, PLoS ONE, May 211 METs Median (min, max) Activity Category Farm Jobs 3. (2.5, 4.5) Moderate Goods-Producing Mining and logging 3.8 (3., 8.) Moderate Construction 4. (1.5, 7.5) Moderate Manufacturing 3. (1.5, 4.) Moderate Service-Providing Trade 2. (1.5, 3.) Light Information 1.5 (1.5, 1.5) Sedentary Financial activities 1.5 (1.5, 1.5) Sedentary Professional and 1.5 (1.5, 2.) Sedentary business services Education and health 2.5 (1.5, 4.) Light services Leisure and hospitality 2.5 (1.5, 3.5) Light Other services 2.5 (1.5, 3.) Light Catrine Tudor-Locke et al Physical Activity Intensity ate US Jobs % Total Priva Light (2. to 2.9 METS) Sedentary (<2 METS) Moderate ( 3. METS) Year Church et al, PLoS ONE, May 211 1

11 Daily Occupational Caloric Expenditure y Expenditure (calories) Occupation Related Daily Energy 1,55 1,45 1,35 1,25 Men -14 daily kcals 1, Year Women -12 daily kcals Men: Predicted Weight Change 95 Predicted Based on Change in Occupation Related Energy Expenditure 9 Weight (kg) Baseline Men Church et al, PLoS ONE, May 211 The Environment has Changed Given the ubiquitous removal of physical activity from work the importance of daily physical activity (exercise) is more important t than ever for both weight and health 11

12 Dose Response to Exercise in Women: DREW Can you stop this decline? If yes, then how much exercise does it take? Can you reverse this decline? If yes, then how much exercise does it take? JAMA, 27; 297: Adherence Across Exercise Groups ge Fitness Percent Chang KKW 8 KKW 12 KKW Study Groups 12

13 Spontaneous Activity ve of Training Daily Steps Exclusiv 4 KKW 8 KKW 12 KKW Months Change in Fitness Percent Change Fit tness Control 72 minutes 136 minutes 192 minutes Study Groups Quality of Life Measures 13

14 Change in Physical Health SPH Control 72 minutes 136 minutes 192 minutes Study Groups Change in Physical Health SPH Control 72 minutes 136 minutes 192 minutes Study Groups Change in Mental Health SMH Control 72 minutes 136 minutes 192 minutes Study Groups 14

15 Summary: The Basic Prescription Accumulate 3 minutes a day, 5 days a week of moderate intensity physical activity Walking, walking and walking However, even 1 minute a day helps but more is better Health Benefits of Aerobic & Resistance Training in Individuals with Diabetes: HART-D Tim Church, M.D., M.P.H., Ph.D. Pennington Biomedical Research Center JAMA, 21; 34:

16 HART-D Participants (n =262): Sedentary individuals with diabetes HbA1c: >6.5% but <11.% Goal: Compare benefit to HbA1c of: Control group Stretching Aerobic training i (AT) 12 kcal/kg/week Resistance training (RT) 3 days per week: 21 sets per day Combination of RT & AT (Combo) 1 kcal/kg/week & 1 set of 9 RT 2 days/week 3 Legitimate Programs 9 Month Intervention All exercise supervised (@ 2, sessions) HART-D Primary Outcomes: Hemoglobin A1c Secondary Outcomes: Fitness and strength Fat mass and lean mass Participants Age Mean (SD) 55.8 (8.7) Female 63.% Ethnicity/race, % African-American 43.5% White 52.7% Other 3.8% Body Mass Index 34.9 (5.9) Waist Circumference, cm 112 (13.8) Relative VO2, ml/kg/min 19.2 (4.2) HbA1c, % Duration Diabetes, years 7.7 (1.) 7.1 (5.5) 16

17 Diabetes Medications Any 97.3 Biguanides (metformin) 65% Sulfonylureas (glipizide) 24% Thiazolidinediones (glitazones) 18% Combination Drugs 16% Incretin Mimetics (exenatide) 1% DPP-4 Inhibitors (sitagliptin) 5% Meglitinides 3% Insulin 18% TOTAL (combo counted 2X) 176% HART-D Training Time Exercising Resistance 141 min/wk Aerobic Combo 14 (13-15) min/wk RT: 3-4 min/wk AT: 11 (1-12) min/wk 17

18 HART-D Intervention Goals Achieved!!! Total exercise time similar across groups Delivered aerobic interventions that met current recommendations HART-D Results HbA1c by Month and Group 7.8 Intention-toTreat Analysis (n=262) 7.7 Control HbA1c, % Resistance Aerobic Combo Month 18

19 Waist Circumference 3 Waist Circumf ference, cm All Sig Vs Control -4 Control Resist Aero Combo Weight 1 Change We eight, Kg Sig. vs Control & RT RT AT Combo Summary For a given amount of time a physical activity program composed of aerobic and resistance is superior to either activities alone HbA1c Fitness Muscle Mass Fat Mass The HART-D combination program consisted of: 11 minutes per week of mod/vig intensity walking 2 days of 9 resistance training exercises each 1 to 12 repetitions per exercise ~2 minutes per day 19

20 Exercise Prescription for Weight Loss & Prevention of Weight Re-Gain Most organizations minutes per day most days 2-3 minutes per week Summary of Exercise Made Simple Obtain at least 3 minutes per day of moderate intensity physical activity 5 or more days a week Something is better than nothing If you are gaining weigh despite this Eat less or do more exercise If you want to lose weight & KEEP IT OFF minutes per day most days has to become part of your life Must be combined with dietary changes Lifting weights is good for you My Recommendations Aerobic 3-4 days a week 45 to 6 minutes Interval or high intensity training at least one day per week Resistance training 1-2 days per week Stretching 3-4 days per week 2

21 Exercise is Medicine 21