1. A strong “PILL” in Chronic Disease Management
EXERCISE
Mitra Nosratabady
2. Leavell’s Levels of Prevention
Stage of disease Level of prevention Type of response
Pre-disease Primary Prevention Health promotion and
Specific protection
Latent Disease Secondary prevention Pre-symptomatic
Diagnosis and treatment
Symptomatic Disease Tertiary prevention •Disability limitation for
early symptomatic disease
•Rehabilitation for late
Symptomatic disease
4. We have done very little to improve
quality of life …
We live longer but not better
It’s down hill after 30?
5. DEFINITION OF AGING
Old and aging depends on the age and experience of the speaker.
•Chronological age - number of years lived
•Physiologic age - age by body function
•Functional age - ability to contribute to society
•Psychological age – conceptual, behavioral and imaging
6. Reality of Aging
•Aging is a natural process – we all age: but
we all age differently
•Burden of Chronic Disease, genetics,
environment, stress and Level of Fitness
influence the aging process
7. PHYSIOLOGICAL THEORIES OF AGING
What causes the body to age?
.Cells replicate 1
.DNA not read correctly 2
.Cell membrane ruptures by free radical or … 3
.NUTRITIONAL MODEL THEORY 4
.collagen in body and hypertension, organ malfunctions 5
.MUTATING AUTO 6-IMMUNE THEORY
.NEURO 7-AGING THEORY: nervous system degeneration
NONE OF THESE THEORIES TOTALLY ACCEPTED
Scientists hypothesize it might be combination of several or all
9. RESPIRATORY SYSTEM
•Lungs become more rigid
•Pulmonary function
decreases
•Number and size of alveoli
decreases
•Vital capacity declines
•Reduction in respiratory
fluid
•Bony changes in chest cavity
10. CARDIOVASCULAR SYSTEM
•Heart smaller and less elastic
with age
•By age 70 cardiac output
reduced 70%
•Heart valves become sclerotic
•Heart muscle more irritable
•More arrhythmias
•Arteries more rigid
•Veins dilate
11. REPRODUCTIVE SYSTEM
Male:
•Reduced testosterone level
•Testes atrophy and soften
•Decrease in sperm production
•Refractory period after
ejaculation may lengthen to
days
Female:
•Declining estrogen and
progesterone levels
12. NEUROLOGICAL SYSTEM
•Neurons of central and peripheral nervous system
degenerate
•Nerve transmission slows
•Hypothalamus less effective in regulating body temperature
•Reduced REM sleep, decreased deep sleep
•After 50% lose 1% of neurons each year
13. MUSCULOSCELETAL SYSTEM
•Adipose tissue increases with
age
•Lean body mass decreases
•Bone mineral content
diminished
•Decrease in height from narrow
vertebral spaces
•Less resilient connective tissue
•Synovial fluid more viscous
•May have exaggerated
curvature of spine
14. Physiologic changes with aging (Board
Questions)
•Decreased
•Muscle mass
•Muscle strength
•Muscle power
•Muscle endurance
•Muscle contraction
velocity
•Muscle mitochondrial
function
•Muscle oxidative enzyme
capacity
16. Strength and Functional Status
“Function”
“Strength”
Poor
Normal
Low High
Healthy
Adults
Frail
Adults
Near
Frail
THRESHOLD
Established Populations for Epidemiologic Studies of the Elderly (EPESE) . J Gerontology,
1994;49(3):M109-15
y, 1994;49(3):M109-15
Deconditioning
18. Functional decline during hospitalization
Am J Phys Med Rehab, 2009, 88(1):66-77
Function
Time
No rehabilitation
Hospital admission
Post Recovery
A
B
Rehabilitation
Threshold of
Independence
19.
20. Improvement of quality of life
Physical
exercise
capacity
20 Age Adapted from Young (1986)
Physically Active
Physically Inactive
‘Minimum necessary
to perform activities
of daily living
21. Opportunities for Physical Activity
•At work
•For transport
•In domestic duties
•In leisure time
The majority of people do very little or no physical activity in any of
these domains
23. Slow walking on a flat surface
3.0 METs
cooking
2.0 METs
sleeping
0.9 METs
Energy Cost
1 MET = 3.5 mL • kg-1 • min-1 V02
Running quickly on a flat surface
12.0 METs
24. Definition of VO2max
•Functional aerobic capacity: Maximal ability
of the body to take in, transport and use
oxygen (Gold Standard)
•Fick Equation:
VO2max
=
(HRmax x SVmax) x (CaO2max -CvO2max)
25. VO2max = (HRmax X SVmax) X (CaO2max - CvO2max)
Genetic Factors (Heart Size)
Conditioning Factors
Contractility/Afterload/Preload
Disease Factors
Wall Motion/Ventricular Fxn
Valve Stenosis or Regurgitation
Exercise
Skeletal Muscles
•Aerobic Enzymes
•Fiber Type
•Muscle Disease
Capillary Density
Exercise
PaO2
Hgb [ ]
SaO2
Diffusion
Ventilation
Perfusion
FICK EQUATION
(220 - Age)
Sinus Node Dysfunction
Drugs (e.g., B - blockers)
Exercise
30. BORG SCALE
Least effort
6
7 Very very easy
8
9 Very easy
10
11 Easy
12
13 More or less difficult
14
15 Difficult
16
17 Very difficult
18
19 Very very difficult
20
Most effort
Resistance
activity
Strength
activity
INTENSITY
31. How Much and How Hard?
Frequency: 3-5 days per week
•Aerobic exercise: a minimum if 3 days a week are necessary to reach most exercise goals
and minimize health benefits
•Strength training: a minimum of 2 days per week
•Flexibility training: a minimum of 3-5 days per week
•Duration
•Aerobic: 20-60 minutes of continuous aerobic activity
•Strength: 1-3 sets of 8-12 repetitions
•Stretching: Stretch all muscle groups and hold positions for 10-30 seconds
32. Principle of Exercise
•Progression
•Then increase duration and/or intensity
•Warm-up, cool-down, and stretching
•Light exercise and stretching performed at beginning and end of exercise
session
43. How Physical Activity Impacts Healt
•Helps control weight.
•Helps build and maintain healthy bones, muscles, and
joints.
•Helps reduce blood pressure in people who already
have high blood pressure.
•Causes the development of new blood vessels in the
heart and other muscles.
•Enlargesthearteriesthatsupplybloodtotheheart.
WHO 2002
44. Health Benefits
•Enhanced cardiovascular function
•Reduction of many cardiovascular disease risk factors
•Increase ability to perform tasks of daily living
•Reduced risk of muscle and joint injury
•Improved work performance
•Improved physical appearance,self-image, and sound mental health
45. Health Benefits
•Reduction of susceptibility to depression and anxiety
•Management of stress
•Enhancement of self-concept and esteem
•Socialization through participation in physical activities
•Improved overall general motor performance, Energy, Resistance
to fatigue
•Reduce the risk of the three leading causes of death: Heart
Disease, stroke, and cancer
•Control or prevent development of Disease
•Enhance Mental Abilities
46. Activity Slows the
Aging Process
•Time dependent aging
•Acquired aging
(related to lifestyle)
Click for info on
compression of
morbidity
49. Importance of Risk Factor Management
Primary and Secondary Prevention
By Lifestyle Changes
50. Burden of Chronic Disease
•Almost two-thirds of Ontarians over the
age of 45 have a chronic disease, and of
those, about 55% suffer from two or
more
•The costs of preventives affairs very
little than chronic disease and indirect
health care costs.
51. LOW LEVEL OF FITNESS
HEART
& BRAIN Disease
DIABETES
ARTHRITIS
High LDL
Low HDL
HYPERTENSION
CANCERS
DEPRESSION
OSTEOPOROSIS
DEPENDENCY
52. Causes of Death 2006-2008
MOH.Statistics2008
Chronic Diseases…………………..
53. Benefits of Exercise for Patients
•Offset deleterious pyschologic and physiologic effects of bed rest
during hospitalization
HM734 Exercise Testing and Prescription: Cardiorespiratory53
54. What’s fat got to do with it?
•Metabolic syndrome
•Vascular disease
•Osteoarthritis
•Gallbladder disease
•Diabetes
•Hypertension
•Dyslipidemia
•Sleep apnea
•Breast cancer
•Colon cancer
•Endometrial cancer
•Impotence
•Osteoarthritis
•Depression
•Disability
Visceral fat selectively mobilizedVisceral fat selectively mobilized
55. Exercise & Cardiovascular Disease
FACT
Sedentary lifestyle is a risk factor for CVD,
according to the American Heart Association
Exercise reduces Blood Pressure
•High blood pressure (above 140/90) is the main cause of Heart Attack and
Stroke
Exercise prevents Atherosclerosis (clogged arteries)
•Exercise reduces cholesterol plaques that clog arteries and can lead to
stroke and heart attackWHO 2002
56. Myocardial Infarction (MI)
Effect of exercise training
.Increase VO 12max (˜%20)
.Improvement 2ventilatory response to exercise
.Improvement anaerobic or 3ventilatory threshold
.Relief 4anginal symptoms secondary (HR, BP) et VO2 in sub-maximal
work.
.5modest decrease in BMI, Movais lipoproteain
.Increase ( 6Antiatherogenic)HDL
.Improve psychosocial well 7-being
.Protection against vigorous physical exertion (≥ 86 METs)
.Decrease coronary 9inflamatory markers (CRP, ,IL6, …)
.Increase endothelial progenitor cells ( 10Promote angiogenesis &
Vascular regeneration)
.Decrease blood adhesiveness, fibrinogen and blood viscosity 11
.Increased 12vagal ton and decreased adrenergic activity.
.13Reduction 20-25% of CV mortality
Vigorous exercise increased fibrosis, deterioration in Left ventricular
function.
From ACSM’s
57. Revascularization
CABGS and PTCA or PCI
.Increase 120% VO2max
.Reduction HR & BP at rest & any given sub 2-maximal work,
Example …
.Improve cardiac autonomic control 3
.Favorable modification of glucose metabolism 4
.20 5-25% reduction of fatal cardiovascular events
From ACSM’s
Effect of exercise training
58. From ACSM’s
Effect of exercise training
A formal exercise training program can be beneficial for cardiac transplant
recipients.
.Decreased blood lactate concentration at a given work rate. 1
.Improved aerobic characteristics of skeletal muscle. 2
.Improved endothelial function. 3
.Decreased 4resting HR and blood pressure.
.Increased VO 52peak and VO2 at ventilatory threshold.
.Improved 6Ventilatory efficiency (Ve/VCO2 slope)
.Increased muscle force production 7
.Increased 8bone mineral density (immunosuppressive medications)
.Countreaction 9of the deleterious effect of immunosuppressive therapy.
Cardiac transplant
59. Exercise and Cancer
The Basics
•Exercise helps to prevent obesity, a major
risk factor for several types of cancer
•Exercise enhances immune function
•Exercise activates antioxidant enzymes that
protect cells from free radical damage
WHO 2002
Potential protective benefits, mirRNA
60. Exercise and Diabetes
Increase insulin sensitivity
Control blood glucose
Control Weight/Lower body fat
Reduce risk of cardiovascular disease
Primary and Secondary (Marefati et al. 2012) prevention demonstrated
Visfatin, Index of Beta Pancras Function,
HbA1C, VO2max
WHO 2002
61. Exercise and Depression
Exercise can help prevent depression. In fact, recent studies have shown
that exercise was found to be just as effective (despite a slower initial
response) as antidepressant medication for treatment of depression.
•Exercise reduces health problems , making you feel better
•Exercise helps you sleep better
•Exercise controls weight, enhancing self-esteemWHO 2002
Lower prevalence and incidence of depressive symptoms
62. Exercise and Your Mind
•Short-term benefits: (increase blood circulatory)
•Boost alertness (possibly by triggering the release of epinephrine and nor
epinephrine)
•Improve memory
•Improve intellectual function
•Spark creativity
•Long-term benefits:
•Exercise has been shown to slow and even reverse age-related decline in mental
function and loss of short-term memory
A report of Surgeon general, Physical Activity and health,
1996
- Dopamine, Serotonin, Beta Endorphin release
Study of Exercise protective against Epilepsy (Marefati et al.)
63. Osteoporosis
•Osteoporosis prevention and treatment
•Stabilization or increase in bone density in pre- and postmenopausal women
with resistive or weight bearing exercise
•1-2% per year difference from controls
•Piso-electric characteristic
•Type of training
64. Dyslipidemia
•Not a lot of data in elderly
•No clear primary and secondary prevention data
•Exercise associated with less atherogenic profiles
•Duration and frequency factors
•Weight loss (or fat loss) associated with increased HDL
•Gender differences with training
•Less training effect on HDL in women
65. Hypertension
•Most trials cross sectional and cohort
•Lower pressures in active individuals
•5-10 mmHg
•Type and intensity
•Greater training effect in those with mild to moderate hypertension
•6-7 mmHg drop in systolic and diastolic pressure
•Effect present in low-to-moderate exercise
66. From ACSM’s
Effect of exercise training
-Longitudinal studies in endurance training reduce 5-7 mmHg in systolic and
diastolic BP.
-A preventive strategy for reduce incidence of high BP recommended by ACSM.
-The possible mechanism of Exercise training in BP reduction are: Decrease in
a. plasma norepinephrins levels,
b. Increase in circulating vasodilator substances,
c. Amelioration of hyperinsulinemia,
d. Alteration in renal function.
-resistance training in comparison aerobic exercise have lower reduction in
resting BP in hypertensive patients.
Hypertension
73. •If you are over 40 or have health problems (heart disease, high blood
pressure, diabetes, obesity, muscle or joint problems) see a physician
before beginning exercise
75. Timing Questions
•What time of day is best?
•Choose the most convenient time for your schedule
•Choose a regular time--the same time every day
•Timing may depend on the activity you choose
•Can I eat before exercise?
•It is best not to eat a meal for 2 hours beforehand
•Be sure to drink plenty of water before and during exercise
•Should I exercise when I’m sick?
•No, especially if you have a fever
76. Injury
•Prevention
•exercise regularly
•gradually increase intensity
•rest between sessions
•warm-up and cool down
•stay flexible
•don’t exercise when sick
•don’t exercise when muscles are
fatigued and straining
•know proper form for any activity you
do
•Caring for Injuries
•Rest: stop immediately
•Ice: apply immediately and repeat every
few hours for 15-20 minutes
•Compress: wrap injured area with elastic
bandage
•Elevation: raise injured area above heart
•After 2 days, apply heat if there is no
swelling
•Gradually ease back into activity when
pain is gone
77. •“Be Active”
•To Lose Weight
•Treat Disease X
•Exercise an Agent …
Why Exercise? Exercise an Agent …
“I exercise because I want
to and I like to enjoy life”
