CPT Tyler J. Raymond D.O., M.P.H. NCS ACOFP Annual Meeting Friday, August 16, 2013

Transcription

1 CPT Tyler J. Raymond D.O., M.P.H. NCS ACOFP Annual Meeting Friday, August 16, 2013

2 Discuss the current obesity epidemic Effects of exercise on morbidity and mortality Review physical activity recommendations Understand specific exercise terminology Writing an exercise prescription Specific considerations (e.g. elderly) Case examples

3 In 1990, among states participating in the Behavioral Risk Factor Surveillance System, 10 states had a prevalence of obesity less than 10% and no state had prevalence equal to or greater than 15%. In 2010, no state had a prevalence of obesity less than 20%. 36 states had a prevalence equal to or greater than 25%; 12 of these states had a prevalence equal to or greater than 30%. CDC: Obesity Trends Among US Adults BRFSS, Available at: obesity_trends_2010.ppt

4 Obesity Trends* Among U.S. Adults BRFSS, 1990, 2000, 2010 (*BMI 30, or about 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30% CDC: Obesity Trends Among US Adults BRFSS, Available at: obesity_trends_2010.ppt

5 64.9% were overweight, with a BMI > % were obese, with a BMI > % of adults achieved at least 300 minutes a week of moderate- intensity aerobic physical activity or 150 minutes a week of vigorous- intensity aerobic 26.4% of North Carolina s adults reported that during the past month, they had not participated in any physical activity CDC: North Carolina State Nutrition, Physical Activity, and Obesity Profile. September Available at: carolina- state- profile.pdf

6 14.6% were overweight ( 85th and < 95th percentiles for BMI by age and sex) 13.4% were obese ( 95th percentile BMI by age and sex) Only 24.1% were physically active for a total of at least 60 minutes per day 36.2% watched television 3 or more hours per day on an average school day CDC: North Carolina State Nutrition, Physical Activity, and Obesity Profile. September Available at: carolina- state- profile.pdf

7 16.2% were overweight (85th to < 95th percentile BMI- for- Age) 15.5% were obese ( 95th percentile BMI- for- Age) CDC: North Carolina State Nutrition, Physical Activity, and Obesity Profile. September Available at: carolina- state- profile.pdf

8 USPSTF and AAFP recommend that all adults with BMI of 30 or greater be offered intensive, multi component behavioral interventions Weight loss in obese individuals is associated with a lower incidence of health problems and a reduced risk of premature death McKinney L, Skolnik N, Chrusch A. AAFP: Diagnosis and Management of Obesity Available at: AAFP/.../patient.../obesity- diagnosis- management.pdf

9 Many physicians do not address obesity with their patients Barriers identified by physicians include: Insufficient time Lack of available referral services Poor reimbursement Perceptions and uncertainty of positive impact Reluctance due to themselves being overweight McKinney L, Skolnik N, Chrusch A. AAFP: Diagnosis and Management of Obesity Available at: AAFP/.../patient.../obesity- diagnosis- management.pdf

10 Reported BMI of US family medicine physicians: 19 24: 43% 25 30: 40% >31: 17% McKinney L, Skolnik N, Chrusch A. AAFP: Diagnosis and Management of Obesity Available at: AAFP/.../patient.../obesity- diagnosis- management.pdf

11 Longevity Quality of Life Socialization Weight Control Disease Prevention Disease Management

12 Strong Evidence: Lower risk of developing cardiovascular disease Lower risk of death from cardiovascular disease Prevention of weight gain Weight loss in combination with dietary changes Reduced symptoms of depression Improved cognitive functioning Prevention of falls ACSM: Exercise is Medicine Available at:

13 Moderate Evidence: Maintenance of weight after weight loss Lower rates of hip fracture Increased bone density Improved sleep quality Lower risk of lung and endometrial cancers ACSM: Exercise is Medicine Available at:

14 Adding physical activity to calorie restriction may result in modest improvements in weight loss Exercise mitigates the damaging effects of obesity and a sedentary lifestyle Maintenance of weight loss has a graded relationship to the amount of exercise that individuals need after weight loss McKinney L, Skolnik N, Chrusch A. AAFP: Diagnosis and Management of Obesity Available at: AAFP/.../patient.../obesity- diagnosis- management.pdf

15 AEROBIC ACTIVITY 150 minutes of moderate- intensity activity per week 75 minutes of vigorous- intensity per week Should be performed for at least 10 minutes per session STRENGTH TRAINING Engage in muscle- strengthening activities that involve all major muscle groups on two or more days per week 8-10 muscle groups 8-12 repetitions Department of Health and Human Services Physical Activity Guidelines for Americans. Available at:

16 Uncontrolled arrhythmia causing symptoms Severe aortic stenosis Uncontrolled heart failure (decompensated) Acute MI Acute pulmonary embolism Acute myocarditis Dissecting aortic aneurysm

17 Low Risk Men<45, Women<55 No cardiac symptoms 1 risk factor Moderate Risk Elderly 2 risk factors High Risk Signs/symptoms of CAD Known CAD or DM Cardiac Risk Factors - - Cigarette smoking Fam Hx. of early CAD - LDL >130 or HDL <35 - Hypertension - Impaired fasting glucose - Obesity (BMI >30) - Sedentary lifestyle

18 Thompson PD, Franklin BA, Balady GJ et al. AHA Scientific Statement: Exercise and Acute Cardiovascular Events. (In collaboration with ACSM). Circulation. 2007;115: USPSTF Screening for coronary heart disease: Recommendation Statement. Ann Int ernal Med icine 2004;140:569.

19 ACC/AHA 2002 Guideline Update for Exercise Testing: Summary Article : A Report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). Circulation. 2002;106:

20 Only rare patients need GXT prior to exercise! AHA 2003: not necessary for people doing moderate intensity USPSTF 2004: Not recommended (Class D) in those at low risk Insufficient evidence (Class I) in those at increased risk

21 Intensity Low Risk Moderate Risk High Risk Moderate Not indicated Not indicated Recommended Vigorous Not indicated Recommended Recommended Always Screen: Patents with known CAD Patients with symptoms of CAD Moderate risk patient for vigorous exercise

22 Exercise: Bodily exertion for the sake of developing and maintaining physical fitness Physical Activity: Body movement by contraction of skeletal muscle which substantially increases energy expenditure Measured by heart rate, VO2max, METs, RPE, etc.

23 Max Heart Rate (MHR) MHR = 220- age (+/- 15 bpm) Heart Rate Reserve (HRR) HRR = MHR - Resting HR(RHR) Target Heart Rate (THR) THR = HRR X TI + RHR TI - Training Intensity, usually 40-60% for moderate exercise

24 VO2max: defined as the functional aerobic capacity Maximum ability of the body to take in, transport, and use oxygen Fick Equation: VO 2 max = (HRmax X SVmax) X (CaO2max - CvO2max) Affected by many factors Age, beta blockers, SA node dysfunction PaCO2, Hemoglobin concentration, SaO2 Heart size, afterload/preload, valvular disease wall motion abnormalities, regurgitation

25 METs: Metabolic Equivalents One MET is equivalent to the amount of oxygen used while resting in the sitting position (3.5 ml O2/kg/min)

26 RPE: Relative Perceived Exertion Scale Subjective measurement of exertion intensity Add a zero to get %MHR Borg GA. Medical Science in Sports and Exercise. 1982;143:

27 Exercise Intensity %MHR VO2max METs RPE Low <50% <45% <4.5 <4 Moderate 50-90% 45-85% High >90% >85% >

28 MD FITT : Mode Duration Frequency Intensity Time Type

29 At least 5 days per week More days are better Dose- response curve

30 Equal to a brisk walk RPE 4-6/10 Pass the talk test Examples: Household cleaning Mowing lawn Leisurely sports Golfing Ballroom dancing

31 Equal to jogging RPE 7-10/10 Fail the talk test Examples: Heavy farming Shoveling Competitive sports Cross- country skiing Biking/Swimming

32 Total of at least 30 minutes per day 10 minute chunks are ok More is obviously better

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34 Large muscle groups 8-12 repetitions Rest 2-3 minutes between exercises 1 set is good 2 sets is better Day of rest in between

35 Anderson RE, Blair SN, Cheskin LJ et al. Encouraging patients to become more physically active: the physician s role. Annals of Internal Medicine. 1997;127(5):

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37 Aerobic Exercise: Same Strength Exercise: Lighter weights repetitions Flexibility Training à 2 days per week, 10 min Balance Exercises à 3 days per week if falls risk Nelson ME et al. Physical activity and public health in older adults: Recommendation from the ACSM and the AHA. Med Sci Sports Exer 2007;39(8):1435.

38 5:2:1 5 servings of fruits and vegetables daily Less than 2 hours of screen time per day At least 1 hour of physical activity per day At least 60 minutes of physical activity per day Vigorous activity at least 3 days per week Strength training 3 days per week Department of Health and Human Services Physical Activity Guidelines for Americans. Available at:

39 Avoid exercise in supine or prone position after 1 st trimester Avoid high heat/humidity especially during 1 st trimester Both weight bearing and non- weight bearing encouraged Heavy weight lifting and activity causing straining discouraged Cycling note recommended due to risk of falls Intensity should not exceed pre- pregnancy levels Artal R, Clapp JF, Vigil DV. ACSM Current Comment: Exercise During Pregnancy. Available at

40 No code for physical activity counseling May code for time if at least 50% of visit is spent counseling or coordinating care Be sure to code for the co- morbid conditions: Hypertension Hyperlipidemia Obesity Depression Osteoarthritis

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