sports medicine
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Are Current Health Care Practices Propagating Obesity in our Youth? The Role of the Physician to Prescribe Solutions Thomas M. Best, MD, PhD, FACSM The Ohio State University. Improving People ’ s Lives through innovations in personalized health care. Sports Medicine. - PowerPoint PPT PresentationTRANSCRIPT
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Sports Medicine
Are Current Health Care Practices Propagating Obesity in our Youth?
The Role of the Physician to Prescribe Solutions
Thomas M. Best, MD, PhD, FACSMThe Ohio State University
Improving People’s Livesthrough innovations in personalized health care
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What Motivates Change?
• There is a crisis• A critical mass of scientific evidence exists• Shift in social attitude occurs• Public cynicism grows• Political pressures begin to build
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What Motivates Change?
• There are 2 kinds of disease; one is pathological, the other is political
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Physical Exercise offers protection against a cluster of diseases
Dementia
Cardiovascular Diseases
Colon cancerDepression
Breast cancer
Type 2 diabetes
Pedersen BK. J.Physiology 2009
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Exercise Deficit Disorder (EDD) in Youth
• Walker GA, Edwards NM, Stracciolini A, Faigenbaum AD, Myer GD. The Use of Exercise-specific V Codes and Reimbursement at a Large Pediatric Medical Center. AMSSM 2013.
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Comprehensive Management Strategies for Management of EDD in Youth
Myer, GD, Faigenbaum, AD, Stracciolini, A, Hewett, TE, Micheli, LJ and Best, TM (2013). "Comprehensive Management Strategies for Physical Inactivity in Youth." Current Sports Medicine Reports July/August.
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Lecture Overview
• Discuss the paradox that exists in youth fitness and sports today.
• Review the wide ranging benefits of PA in kids and implications of an inactive youth population.
• Talk about current messaging on youth health behaviors
• Discuss the role of the physician and healthcare systems in assessing and prescribing exercise.
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Youth Fitness and Sports Paradox
• Survey of HS seniors:– Less than 25% of boys and 15%
of girls exercise vigorously .– Childhood obesity is an
emerging epidemic.• However;
– Half the exercising group is actively involved on an athletic team, many participating all year.
– Increased risk for orthopedic injury, especially related to overuse.
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• The Changing Landscape of Playgrounds!– Most exercise obtained by
children in America is no longer obtained in physical education class or free play; it comes through organized youth sports.
– Children are less fit and obesity is growing, yet so is athletic injury!
Youth Fitness and Sports Paradox
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Physically Inactive kids at greater risk for injury!
• Study of 995 children aged 9-12 years.– Low levels of habitual PA have
significantly increased injury risk.• The children at highest injury risk
are the target audience of the contemporary PA promotion efforts.
• Therefore, PA promotion should focus on injury prevention as well.
Bloemers BJSM 2011
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Benefits of Physical Activity in Kids
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Why Kids Should Exercise
• Compared to kids who don’t exercise, kids who do:– Can run longer and faster– Have stronger bones– Have stronger muscles– Are less likely to be fat– Have less stress and depression– Are less likely to develop chronic
diseases– Are more likely to be healthy
adults
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Exercise Helps Prevent:
• Diabetes• Cancer (breast and colon)• High blood pressure• Depression• Osteoporosis • Alzheimer’s disease• Heart attacks• Dying early
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Physical Activity Improves Mental Health
• Regular PA may increase self esteem
• Regular PA may decrease anxiety/depression*
• Some evidence shows teen girls have lower rates of sexual activity and pregnancy when PA increased
• Some evidence regular PA associated with decreased smoking, alcohol and drug abuse
K.J. Calfas, W.C. Taylor. Ped Exerc Sci 1994. 6:406-423Sabo et al. J Adolesc Health 1999;25:207-16
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Fitness And Stanford Achievement Test 9th Ed SAT-9 and Fitnessgram Results
• Fitnessgram test:– 1. Aerobic Capacity– 2. Body Composition (% of body fat)– 3. Abdominal Strength and Endurance– 4. Trunk Strength and Flexibility– 5. Upper Body Strength and Endurance– 6. Overall Flexibility
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353,000 Students
Number of Fitness Standards Achieved
Source: California Dept. of Education Study, December 10, 2002
10
20
30
40
50
60
70
80
1 2 3 4 5 6
Grade 5SAT 9 and Physical Fitness
Reading Mathematics
0
29
3632
4036
4540
5046
58 55
71
SAT
9 Pe
rcen
tile
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0
10
20
30
40
50
60
70
1 2 3 4 5 6
SAT
9 Pe
rcen
tile
322,000 Students
Source: California Dept. of Education Study, December 10, 2002
Grade 7SAT 9 and Physical Fitness
26 2831 32 34 36
4144
5054
60
66Reading Mathematics
Number of Fitness Standards Achieved
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279,000 Students
Reading Mathematics
21
35
24
38
28
43
31
51
37
58
45
67
Source: California Dept. of Education Study, December 10, 2002
Grade 9SAT 9 and Physical Fitness
0
10
20
30
40
50
60
70
SAT
9 Pe
rcen
tile
1 2 3 4 5 6Number of Fitness Standards Achieved
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300
310
320
330
340
350
360
370
380
0 1 2 3 4 5 6Number of Fitness Standards Achieved
CST
E-LA
Mat
h Sc
ore
Source: California Physical Fitness Test, 2004 Results, Calif. Dept. of Ed., April 2005
371,198 Students (203,726 NSLP and 167,472 Non-NSLP)
Socioeconomic Status** & Number of Fitness Standards 2004 CST* Scores in English- Grade 5
*California Standards Test**National School Lunch ProgramResults using math scores were consistent with those using English-Language Arts scores. Results for seventh- and ninth-grade students were consistent with those for fifth graders.
Non-NSLP NSLP
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0% 10% 20% 30% 40% 50% 60% 70%
Strength Test
Flexibility Test
Pacer Test(Cardiovascular Fitness)
Paced Curl-Up
Push-Up
Modified Sit & Reach
Improvements in Fitnessgram ResultsPE 4 Life Program at 6 months
Woodland Elementary School, Kansas City PSDFall 2005 – Spring 2006, Grades 4 and 5
Fall 2005 Spring 200613.5 %21.6 %
16.5 %
12.7 %
12.4 %
4.5 %
19.4 %
28.1 %
31.1 %
59.6 %
3 %16 %
88%
60%
127%
207%
182%
433%
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2004 - 20052005 - 2006
0 200 400 600 800 1000 1200 1400
Resulting Out-of-School
Suspension Days
Discipline Incidents Involving Violence
228
1177
392
94
Percent Reduction in Disciplinary IssuesPE 4 Life Program at 6 months
Woodland Elementary School, Kansas City PSD #33Fall 2005 – Spring 2006, Grades 4 and 5
59%
67%
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Hillman CH et al. Med Sci Sports Exerc 2005; 37:1967
Fitness and Neurocognitive Functionin Preadolescent Children
• 24 children, mean age, 9.6 years• Fitness assessed by FITNESSGRAM• Neurocognitive function assessed by
responses to a stimulus discrimination task• Fitness was positively associated with
attention, working memory, response speed, and cognitive processing speed
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How Much Physical Activity Do Kids Need?
• Children and adolescents should do 60 minutes (1 hour) or more of physical activity daily.– Aerobic Activities: most should be either
moderate or vigorous intensity PA. Include vigorous-intensity PA at least 3 days per week.
– Muscle-strengthening Activities: at least 3 days of the week, as part of the 60 or more minutes.
– Bone-strengthening Activities: on at least 3 days of the week, as part of the 60 or more minutes.
• Activities should be age-appropriate, enjoyable, and offer variety.
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JAMA. 2008;300(3):295-305. doi:10.1001/jama.300.3.295
Kids exercise less as they get older
Girls weekend12.6 yrs
Boys weekday14.7 yrs
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% of High School Students Meeting Guidelines
23.718.5 15.5 14.9
17.1
10.5
0
20
40
60
80
100
Total Female Male White Black Hispanic
Perc
ent
* Were physically active doing any kind of physical activity that increased their heart rate and made them breathe hard some of the time for a total of at least 60 minutes/day during the 7 days before the survey.Source: National Youth Risk Behavior Survey, 2007.
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When are elementary school students active?
010002000300040005000600070008000
P.E. School Day OutsideSchool
BoysGirls
Morgan CF, et al (2003) Journal of Physical Education Recreation and Dance, 74(7), 33-38.
Step
s per
day
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NHANESPrevalence of Overweight Youth Ages 2-19
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Chronic Disease in Children
• Pediatrics; Nov 08’ Number of children taking meds for chronic diseases jumped dramatically in past 3 years.– Diabetes 103% increase
(kids as young as 5)– Asthma 47% increase– ADHD 41% increase– Cholesterol 15% increase
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Where will we find our future?
• Firemen• Police officers• Prison guards• Soldiers• Lifeguards• Construction
workers
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“The Freshman 15?”• Studies suggest actual weight
gain during 1st year of college is:– ~6 lbs in men– ~4.5 lbs in women.
• What are the causes?– Not enough exercise.– Poor diet – fast food,
dormitory food, skipped meals.– Poor sleep habits– Stress.
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2000
Obesity Trends* Among U.S. AdultsBRFSS, 1990, 2000, 2010
(*BMI 30, or about 30 lbs. overweight for 5’4” person)
2010
1990
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
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Obesity Hysteria
• The world has now been sufficiently alerted to the global problem of obesity.
• Patients have been labeled and stigmatized.
• Assigned lots of blame.• Spent lots of money.• …and gotten nowhere.
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Are patients and their physicians giving up?
• Data from National Ambulatory Medical Care Survey for 1995-96’ and 2007-08’ showed:– During this period, adults who were overweight or
obese increased from 52.1% in 95’ to 63.3% in 08”.– Patients seen in 2007-08; had 46% lower odds of
receiving weight counseling than 95-96’.– Patients with hypertension 46% less likely and diabetics
59% less likely to receive counseling.• The campaign on obesity is not working!• What’s the definition of insanity?
Kraschnewski, et al, Medical Care, 2013
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• We need to give patients permission to be fat; And still be healthy!
• Shift focus off of BMI and onto physical activity.
• Health At Every Size (HAES)– Focus on broader health.– 95% regain lost wt. in 3-5 yrs.– Change in BMI is not a success
measure for an exercise program.
We need a new (and fresh) approach!
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Death Rates by Fitness & BMI Categories
0
10
20
30
40
50
60
70
<27 27-30 >30
Deat
hs/1
0,00
0 M
Y
Barlow et al. Int J Obes 1995; 19:Suppl 4, S41-4
Low fitMod fitHigh fit
after adjustment for health status, smoking, glucose, cholesterol, & BP
Normal ObeseOverweight
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• Large scale exercise prescription initiative in adults and kids:– Every patient; Every visit;
Every treatment plan.• Physical activity should be recorded
as a vital sign and kids encouraged to do 60 min of exercise per day.
• Message should be the same from every medical provider.
• We must begin to merge fitness with healthcare.
What can we do?
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Smith, Johnny 12 yrs M
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0 Minutes: Running late? Too many other concerns on the patient’s list? Relax.
Perhaps you can discuss physical activity at next visit. Hopefully office staff will have assessed exercise and provided resources.
1 Minute for Advice: Quickly congratulate kids (and their parents) who are getting 420
minutes or more per week of moderate-vigorous physical activity. Advise patients who are getting fewer than 420 minutes of the
importance of physical activity, especially linking benefits to the child’s complaints, problems and health risks.
What Can Busy Physicians Do to Encourage Physical Activity?
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What Can Busy Physicians Do to Encourage Physical Activity?
2 Minutes for a Prescription:
Review key messages about the importance of physical activity. Offer a generic Exercise Prescription. Suggest useful ideas (e.g. walk to school, bike transportation, active
games, after-school activity, family fitness activities).
5 Minutes for Brief Counseling:
Assess readiness for change regarding exercise habits. Ask what the child might want to do to be more active and barriers
to prevent this from happening -- brainstorm on how to get around them.
Explain to parents in detail how exercise affects health and development and their child can go about incorporating it into their life.
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• Days per week in 153,746 kids age 12-17 (year ending 1/31/13):– 15.2% report 0 days per week.– 15.7% report 1-4 days per week.– 69.1% report 5 or more days/wk.
• Percent reporting >150 min mod exercise per week:– 77.5% in 12-17 yrs.– 34.5% in 18-64 yrs.– 29.8% in 65+ yrs.
EVS in Kids; Kaiser Permanente
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“At Kaiser Permanente, we want you to Live Well, Be Well and THRIVE!”
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Kaiser Permanente – “Kid Wisdom”
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Summary
• Youth sports/activity paradox – kids are doing too much or too little.
• The wide ranging benefits of PA in kids and adults are well established.
• We need to encourage kids to be Healthy at Every Size by engaging in regular PA.
• Physician have an important role to play in promoting PA for health– An Exercise Vital Sign is an easy way to bring a
discussion on PA into the exam room.– Even brief advice can have a significant affect.
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• Mississippi State• U of Arizona• Georgia Tech• Lewis & Clark College• U of South Florida• Joliet College• Kentucky Wesleyan• Roanoke College• UCCS• Penn State• Slippery Rock
A Call-to-Action