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Technology, Networking and Best Practice in Physical Education and Health: Local to Global
Steve Kopecky MD FACC, FAHA, FACP, FASPC Professor of Medicine
Division of Cardiovascular Diseases Mayo Clinic
Role of Physical Activity in Reducing Chronic Disease
Disclosure: Conflict of Interest Stephen L Kopecky
Research Grants NIH/NHLBI Regeneron/Sanofi-Research Grant Amgen – Research Grant
Consultant •Applied Clinical Intelligence: DSMB Chair •Prime Therapeutics – Formulary Committee •Merck- Atherosclerosis Advisory Board
Board of Directors Mayo Clinic Support Services, Texas American Society for Preventive Cardiology, IPP American Society for Men’s Health
How to Prolong a Healthy Life B A S E
Keep <30. Waist < 35” (woman); <40” (man) MI : ctive : Vigorous leisure activity > 2 ½ hours per week moke : Don’t at : 5 Fruits +/or Vegetables per day
How does this help ? Reduces : Dementia, Stroke, Parkinson’s Heart Attack Diabetes, Metabolic Syndrome Arthritis
Reduces : Organ failure & Frailty Death Prolongs : Active, meaningful, and engaged life
How many ways to die are there ?
Patterns of Functional Decline at the End of Life JAMA. 2003;289(18):2387-2392.
Sudden Death Terminal
Illness
Most effective way to avoid Organ Failure and Frailty: •Non-smoking • Regular Vigorous Physical Activity •Eating F/V’s •Ideal Weight
Func
tion
Func
tion
Organ Failure Frailty
“Lack of activity destroys the good condition of every human being, while movement and methodical physical exercise save it and preserve it”.
Plato
There is a positive ‘halo effect’ around starting a physical activity program
Smoking Weight Vigorous Leisure Activity
Stop Lose Start
- Poor eating choices & gain weight - Usually ‘crash’ diets and regain weight - Less smoking, Better eating choices Regular activity is associated with sustained wt loss
Goal Activity Effect
Human body is programmed in such a way that most of its systems (eg, skeletal, muscle, metabolic, and cardiovascular) do not develop and function optimally unless stimulated by frequent physical activity 1
1 Booth et al Reduced physical activity and risk of chronic disease: the biology behind the consequences. Eur J Appl Physiol 2008; 102: 381–90. 2 WHO. Global health risks: mortality and burden of disease attributable to selected major risks. Geneva: WHO, 2009.
Why be physically active ?
Technological revolution – great benefit to many, but a major cost in terms of physical inactivity. In 2009, physical inactivity identified as fourth leading risk factor for non-communicable diseases and accounted for more than 3 million preventable deaths.2
Men
Women
Inactivity
What happens with age ? Inactivity rises with age Who is more active – women or men ?
How physically active are adults worldwide ?
Lancet 2012; 380: 247–57
Worldwide : 31% (95% CI 30·9–31·2) physically inactive
Who is least and most active ? Lowest : SE Asia 17% (16·8–17·2) Highest : Americas and E Mediterranean 43%
Men and is increased in high-income countries
What about the youth ? Proportion of 13–15-year-olds doing <60 min of mod-vigorous physical activity/d is 80% (80·1–80·5); boys more active than girls
Relationship Between Physical Activity and CV Risk
Powell KE, Paluch AE, Blair SN. Physical activity for health: what kind? How much?How intense? On top of what? Annu Rev Public Health 2011;32:349–65.
Highest risk is Physical Inactivity
High aerobic exercise volumes associated with lowest risk
Similar increase in activity yields different risk reductions
J Am Coll Cardiol. 2015; 65(19):2091–100. CRF= cardiorespiratory fitness
assuming constant waist circumference
Level of CRF Overall Hi Mid Low
Age
Tota
l Cho
lest
erol
M
g/dL
Abnormal
95% confidence interval
Trajectories of Total Cholesterol With Aging and Fitness
CRF delays elevated cholesterol by ~15 years
Telomere Length and Risk of MI in Multi-Ethnic Population
D’Mello et al JACC 67(15);19 April 2016, Pages 1863–1865
When telomeres shorten too much, cell division stops
Telomere
Telomere Length and Risk of MI in Multi-Ethnic Population
D’Mello et al JACC 67(15);19 April 2016, Pages 1863–1865
Exercise lengthens telomeres thus reducing MI Risk
Phys Active (>4 hr mod activity/wk vs <4 hr)
Record number of Americans Report Exercising in 2015
Winter = low; Summer = High % Exercising >30+ Min > 3 days/week
Americans exercise more in summer than winter
Source: Behavioral Risk Factor Surveillance System (BRFSS)
People reporting no physical activity in the last month
http://www.cdc.gov/physicalactivity/
2010
http://www.juststand.org/
Sedentary time in adults : Association with DM, CV Disease and
Death
Even if you exercise regularly, high sedentary time increases CV risk
equal to smoking a ½ pack a day
Every 2 hours, get up and walk vigorously for 2 minutes
Diabetologia (2012) 55:2895-2905
What is the relationship between fathers’ and preschool-aged children’s BMI, diet quality, and physical activitya Variable B+/- standard P value error b Total fruit Total vegetables Dairy Weekend activity (total min) Sedentary Moderate intensity Vigorous intensity
a Covariates included father’s race, ethnicity, and income level b Child-related variables as predicted by paternal-related variable
.18+/-.08 0.03
.29+/-.06 <0.0001
.00+/-.07 0.70 .08+/-.08 0.33 .14+/-.39 0.73 .62+/-.18 0.001
Vollmer et al J Acad Nutr Diet. 2015;115:919-926
Clear relationship between fathers’ and children dietary intake and physical activity level
Normal weight father and obese mother : was not a significant predictor of child weight Obese father and normal-weight mother : increased the child’s likelihood for being overweight 4-Fold.
Freeman et al Preventing and treating childhood obesity: Time to target fathers. Int J Obesity. 2012;36:12-15.
Which parents weight and lifestyle most influences a school-aged child ?
At what age does a Child’s Vigorous Physical Activity Correlate with CV Risk later in life ?
Boys Age 2-6 yrs Girls
Age 6-9 yrs
CV
Ris
k Sc
ore
Quintiles of Vigorous Activity (Min/Day) 1 2 3 4 5 1 2 3 4 5
The more vigorous regular activity by age 6-9, the lower CV risk later in life
Jiménez-Pavón et al. BMC Medicine 2013 11:172 doi:10.1186/1741-7015-11-172
What practices reduce the risk for obesity in preschool age children ?
TV/Screen viewing time1 Increased screen time is positively associated with obesity
Shared family meals3 Frequency of shared family meals inversely associated with obesity
1 Int J of Ped Obesity 1(2);103–108:2006 2 J of the Am Dietetic Assoc, 110(7);1049–1057:2010 3 Pediatrics 125 (3);420–428:2010 4 Amer J of Clinical Nutrition 88(6);1459–1468:2008.
Physical activity/active play time2 Physical activity time inversely associated with obesity
Fruit and vegetable consumption4 Higher availability or consumption of fruit +/or vegetables associated w/ lower total energy consumption and body weight and healthier body composition
Screen Viewing Time and Active Play •Am Acad of Pediatrics1 recommends : Children <2 yrs not be exposed to TV Children >2 limited to 1-2 hours of quality programming for TV viewing and screen use •Survey data show that: Watch videos, DVD’s, or TV 2 By 3 months of age, 40% regularly watch Children <2 yrs , 90% watch daily •Early activity patterns persist into childhood 3
1 Barlow Pediatrics, vol. 120, pp. S164–S192, 2007. 2 Zimmerman Archives of Pediatrics and Adolescent Medicine, vol. 161, no. 5, pp. 473–479, 2007. 3 Certain Pediatrics, vol. 109, no. 4, pp. 634–642, 2002.
BMI during Adolescence and Subsequent CV Mortality
Baseline:Age 16-19 yrs n=2,298,130 F/U 42 Mill person-yrs
Cum
ulat
ive
C
V M
orta
lity
(%)
Year of Follow-up BMI >85th %tile in late years
increases risk of early CV death 2-3 fold Twig G et al. N Engl J Med 2016. DOI: 10.1056/NEJMoa1503840
*adjusted for sex, age, birth year, education, socioeconomic status, country of origin, and height
These findings suggest that higher midlife fitness may be associated with the compression of morbidity in older age
Willis et al Arch Intern Med. 2012;172(17):1-8
Does Midlife Fitness Effect the Development of Chronic Conditions in Later Life ?
Bad genes raise heart attack risk by factor 1.3-1.4, Bad lifestyle raises heart attack risk by factor 3-4 !
Chetty et al JAMA. doi:10.1001/jama.2016.4226
Bottom income quartile, 1996-2008
Lighter color = more exercise
Women
Exercise
Lighter color = Longer life span
Life Span
Even in lowest income, life expectancy variation mostly related to behaviors : smoking, obesity, and exercise
Physical Activity vs Cardiorespiratory Fitness
Cardiorespiratory Fitness
Physical Activity
50% increase in ED if your gut is so big you cant see your junk
1 in 3 men in UK can’t see it !
Am Soc for Men’s Health Conference Wash DC 2015 ED=Erectile Dysfunction
We Love Our Health.co.uk commissioned a survey of 1,000 men that
found that because of the size of their bellies, “1/3 of men in Britain age 35-60
years are unable to see their penis" when they stand upright and look downwards.
http://www.digitaljournal.com/article/336489#ixzz3trgF9rio
The "Big Check" campaign : Dr Sarah Brewer, said, "Men care more about maintaining their cars than their own bodies, and often only see the doctor if told to by a female partner or relative."
American Journal of Public Health: September 2015, Vol. 105, No. 9, pp. e54-e59. doi: 10.2105/AJPH.2015.302773
99,791 obese women and 76,704 obese men
BMI (kg/m2) Probability of attaining normal weight 30.0–34.9 40.0–44.9
How often can obese become non-obese ?
If a 5% weight reduction achieved, 80% regain it at 5 years .
Women : 1 in 124 Men : 1 in 210
Women : 1 in 677 Men : 1 in 1290
Cardiorespiratory Fitness
Physical Activity
What reduces CV Risk most : Physical Activity or CV Fitness ?
Williams PT Physical fitness and activity as separate heart disease risk factors : a meta-analysis Med Sci Sports Exerc 2001;33:754-761
CHD= Coronary Heart Disease CVD= CHD plus Stroke
What reduces CV Risk most : Physical Activity or CV Fitness ?
CHD=Coronary Heart Disease CVD=CHD plus Stroke
Williams PT Physical fitness and activity as separate heart disease risk factors : a meta-analysis Med Sci Sports Exerc 2001;33:754-761
Dose response curve for the relative risk of either CHD or CVD
25%
60%
Both beneficial: ‘Fitness’ better than ‘activity’ to reduce CV Risk
Physical Activity : What types help the most ?
There are 4 proven beneficial categories:
*Brisk walking **Jogging-running
2) Muscle-strengthening : > 2 days/week 3) Avoid prolonged sitting : Move for 100 seconds every 30 min (Lowers fasting blood sugar, lowers insulin levels, lowers triglycerides)
1) Aerobic : Mod-Vigorous* ~150 min/week Vigorous** ~ 75 min/week
Point-of-decision prompts
‘I want to climb the stairs to fitness’
Healthy Advertising
www.inudgeyou.com
Social Media Links
Singapore : Bugis MRT Station
PA Education
What does the research tell us about ‘Brain Breaks’ type of activity ?
2-min walking breaks
every 20 min
for 1-2 weeks
5 Hr Postprandial Glucose : After 2-hr of sitting
There is an individual ‘dose response curve’ to activity : More and Intense activity leads to better glucose control
Area
Und
er th
e C
urve
(In
crem
enta
l)
Participant ID
sitting sitting w/ light-intensity activity breaks (RPE 8) sitting w/ mod-intensity activity breaks (RPE 12)
AUC (mmol/L-hr) 6.9 5.3 4.9
Dunstan et al. Diabetes Care 2012;35(5):976–83
What does Fitbit data tell us about motivation* ?
* Eric Friedman FitBit CIO - Personal communication
Number of Steps per day Num
ber o
f ind
ivid
uals
mea
sure
d
0 2500 5000 10000
“If we can find what motivates you, we can get you to be more active”
Examples of Text Messages Used in the TEXT ME Randomized Clinical Trial
Physical Activity : Hi [NAME], don’t forget physical activity is good for you! It reduces your risk of diabetes, heart attack, stroke, and their complications. Walking is cheap. It can be done almost anywhere. All you need is comfortable shoes & clothing.
JAMA. 2015;314(12):1255-1263. doi:10.1001/jama.2015.10945
TEXT ME Randomized Clinical Trial : 6 Month Results
LDL : significantly lower Reductions in : systolic blood pressure and BMI, Tob Increases in : physical activity, Participants reported the text messages to be : useful (91%), easy to understand (97%), and appropriate in frequency (86%).
In patients with coronary heart disease, a lifestyle-focused text messaging service (vs usual care) resulted in a modest improvement in LDL & greater improvement in other CV disease risk factors.
JAMA. 2015;314(12):1255-1263. doi:10.1001/jama.2015.10945
In what year was it shown that there are more people worldwide that are obese (BMI >/=30) than significantly underweight (BMI </= 18.5) ? A 2000 B 2006 C 2016 D Estimated to occur in 2026 E Never been shown
Lancet 2016
We are focusing on drugs to treat , when it would be better to focus on lifestyle to prevent
Atrial Fibrillation = Irregular heart beats
Rahman, F. et al. (2014) Global epidemiology of atrial fibrillation Nat. Rev. Cardiol. doi:10.1038/nrcardio.2014.118
Global Prevalence and estimated increase of Atrial Fibrillation (%) by 2050
Pathak et al JACC 2015;66(9):985-96
Gained < 2 METS
Gained > 2 METS
18%
61%
0%
10%
20%
30%
40%
50%
60%
70%AF Free w/o drugs or ablation
Pathak et al CARDIO-FIT Trial JACC 2015;66(9):985-96
Every MET gained = 9% decline in AF *
*Adjusted for weight loss and BL CRF
Can an improvement in CRF lower Afib Recurrence ?
CRF = Cardiorespiratory fitness AFib= Atrial Fibrillation BL= Baseline
Kaplan-Meier Plot with 95% confidence limits
How much is survival effected by fitness ?
JAMA Submitted
Functional aerobic capacity : 1=<75%, 2= 75%-89%, 3=90%-104%, 4=>105%
Exercise Treadmill Stress Testing
20% Difference
n=12,403
Each increase of 10% in FAC was associated with a decrease in all-cause mortality by 16%
[0.84 (0.82-0.86, p<0.0001)]
Maternal-age-associated risk of congenital heart disease is modifiable
Schulkey et al Nature 520;230-233: 2015
Exercise during pregnancy can help reduce congenital heart defects
VSD= Ventricular septal defect
Public Policy
Family & Social
Networks
Physical &
Social Environs
Community Support
for Healthy Lifestyles
Educators & Schools
Employers & Worksites
Health Plans & Payors
Faith Based Orgs
Building Healthy Lifestyles
to Reduce Chronic Diseases Increased Physical Activity
Improved Nutrition
Decreased Tobacco
Use & Exposure
Decrease Harmful Alcohol
Use
Practical Positive Thinking
Improved Sleep Hygiene
6
8
Requires Personal and Community Efforts
Community Support for Healthy Lifestyles • Individuals - increasingly motivated to adopt/maintain healthy life-styles through community-level initiatives, particularly through employers and worksites • Community supports, in collaboration with the health care system, contribute to healthy lifestyles • All stakeholders should publicly support those measures that promote healthy lifestyles and recommend them to their patients Only these types of interventions are likely to have the
needed impact to engage, motivate and support people to make needed improvements
Brownson RC, Haire-Joshu D, Luke DA. Shaping the context of health: a review of environmental and policy approaches in the prevention of chronic diseases. Ann Rev Public Health 2006;27:341-70.
Increasing physical activity
You cannot overestimate the importance of what you are going
“Never doubt that a small group of thoughtful, committed citizens can change the world…..
indeed, it's the only thing that ever has.”
Margaret Mead American anthropologist 1901-1978
Thank you for your attention !