CVD Risk Factors

LIPIDS (mg/dl) Total Cholesterol > 200 LDL-Cholesterol > 130 HDL-Cholesterol < 40 TG >150

NONLIPID RISK FACTORS

Modifiable Non modifiable

A.T.P. III

Non-lipid Risk Factors

Modifiable Risk Factors

Hypertension Obesity Diabetes Thrombogenic/

Haemostatic State Cigarette Smoking Physical InactivityPhysical Inactivity Atherogenic Diet

Non modifiable Risk Factors

Age Male Sex Family History of

Premature CHD

A.T.P. III

Life-style factorsLife-style factors

Reduction of CVD Risk Factors

Physical activity both prevents and helps treat many established atherosclerotic risk factors;- Low HDL-Cholesterol concentrations- Elevated Triglyceride concentrations -Insulin Resistance and Glucose Intolerance-Elevated Blood Pressure- Obesity

A meta-analysis of 52 exercise training trials of > 12 weeks’ duration including 4700 subjects demonstrated:

[HDL-C] 4.6% [TG] 3.7% [LDL-C] 5%

Physical Activity and Blood Lipids

Leon A.S. et al Circulation 2001

“Heritage” Study

Subjects: 200 men, age < 65 years, with sedentary attitudes

Training: 60 sessions of aerobic training, 21 weeks (1-4 sessions/week)

Exercise effect on blood lipids

Couillard, ATVB 2001

Physical Activity and Blood Pressure

• 44 randomized control trials (2674 particpants) have studied the effect of training exercise on resting blood pressure

Normoitensive subjects

Hypertensive Subjects

SBP 2,6 mmHg

SBP 7,4 mmHg

DBP 1,8 mmHg

DBP 5,8 mmHgExercise may serve as the only therapy in middle hypertensive subjects

Fagard RH. Med Sci Sports Exerc. 2001

•Sedentary patients should be advised to take up modest levels of aerobic exercise on a regular basis (walking, jogging or swimming for 30–45 min for 3-4 times/week) • Isometric exercise such as heavy weight-lifting can have a pressure effect and should be avoided. • If hypertension is poorly controlled in severe hypertension, heavy physical exercise should be discouraged or postponed until appropriate drug treatment is effective.

Physical Activity and Blood Pressure

EHS-ECS Guide-Lines for the management of Hypertension. J. Hypertens. 2003

Physical Activity and Obesity

•Increases Cardiorespiratoty Fitness indipendent of weight loss

(A)

•Indepentendly reduces CVD risk factors (A)

•Improves insuline action and reduces insulin resistance (A)

•Increased aerobic activity reduses blood pressure

independently of weight loss (A)

•If accompanied by weight loss affects favorably blood lipids (A)

NHI and ACSM Evidence Statements

G.A Bray, C. Bouchard. Hand Book of Obesity, 2004

Physical Activity and Endothelial function

Physical Activity may also (some hypothesis):1. Enhance endothelial function by increasing the production

of nitric oxide and prostacyclin2. Reduce LDL oxidation3. Decrease the atherogenic activity of Mononuclear Cells by

affecting the production of cytokines4. Decrease the number of atherosclerotic lesions by reducing

heart rate and pulsatile stress5. Decrease the accumulation of collagen in the artery wall

A. Cherubini et al. Aging Clin. Exp. Res. 1998

The Nurse’s Health Study (72.488 subjects) data have demonstrate that:

1. Physical Activity is associated with reduced Risk of Total and Ischemic Stroke in a dose-respond manner.

2. Physical Activity level had no significant relationship with Subaracnoid or Intracerebral Haemorrhage.

3. Similar energy expenditure from walking and vigorous exercise confer similar reduction in stroke risk.

Physical Activity and Stroke

Frank B. et al. JAMA. 2000

Physical Activity and Stroke

Relative risk of Stroke, according to usual walking pace (Nurse’s study)

0

0,2

0,4

0,6

0,8

1

1,2

Total strokes Ischemic strokes Hemorr. Strokes

Easy < 3,2 km/hModerate 3,2 - 4,8 km/hBrisk >4,8 km/h

Hu et al, JAMA 2000

Hu et al, Ann Int Med 2001

The age-adjusted RR of new cases of CVD, according toAverage hours of vigorous activity per week were:

<1 1-1.9 2-3.9 4-6.9 >7

1.00 0.93 0.82 0.54 0.52Phys. act, hrs/week

CVD, Rel. Risk:

Relative risk of cardiovascular events in diabetic women of the Nurse’s Study according to physical activity level

Physical Activity and CHD

Physical Activity and Claudicatio

Physical Activity is an effective treatment for improving walking distanceAccording to a meta-analysis of 21 exercise programs:

•average distance to pain onset increased 179% or 225m•average distance to maximal tolerated pain increased 122% or 397m

Exercise and Physical Activity in the Prevention and treatment of Atheroslerotic Cardiovascular Disease. AHA. Circulation 2003

• People > 65 years constitute a growing portion of word population population .• Age represents an independent, non modifiable CVD risk factor.• Age is no contraindication to being more active.• In elderly physical activity could prevent CVDprevent CVD and morbidity morbidity and disabilitydisability.• Aerobic activities with low impact in Aerobic activities with low impact in muscoskeletal system and jointsmuscoskeletal system and joints (brisk walking, swimming, cycling…)

Physical Activity in Elderly

Cherubini A. et al. Aging Clin Exp Res. 1998

Walking Compared with Vigorous Exercise for the Prevention of Cardiovascular Events in Women

JoAnn E. Manson N Engl J Med 2002

Aerobic exercise training reduces plasma endothelin-1 concentration in older women Seiji Maeda J Appl Physiol 2003

Prevalenza della sedentarietà in anziani americani

05

10152025303540

45-64 65-74 > 75

UominiDonne

%

BRFSS, 2001

CDC, 2001Età

Percentuale di soggetti non istituzionalizzati con regolare attivita` di resistenza 3 volte o piu` alla settimana, secondo dati

del NHIS

18-29 30-44 45-64 > 65

0

20

30% soggetti

attivi

Gruppi di eta`Caspersen et al., 1988

10

10% 8%5%

7.8%

Percentuale di soggetti ultra-sessantacinquenni che seguono le raccomandazioni

dell’ NHIS per l’attività fisica in relazione a diversecaratteristiche della popolazione (n=5537)

CDC, 2001

20,56,6

206,1

6,9

13,39,5

12,6

0 3 6 9 12 15 18 21 24

Sesso

percentuale

DonneUomini

BMI > 30< 25

SaluteScadente

EccellenteScolarità

ElementareUniversitaria

peso corporeo altezza grasso corporeo con ridistribuzione centrale dell‘adipe massa muscolare

Modificazioni della composizione corporea associateall` invecchiamento

Modificazioni della composizione corporea e della distribuzione del grasso corporeo

dopo esercizio di resistenza

%grasso corporeo totale e della massa grassa

WHR e del tessuto adiposo viscerale

valutato con TAC

FFM a livello della coscia

W. M. Kohrt et al.,1992

Modificazioni muscolari legate all`invecchiamento

forza muscolare massa muscolare totale numero e dimensione fibre tipo II unita` motorie processi neuropatici numero e dimensione mitocondri attivita` enzimi ossidativi

Fiatarone M. A. et al.,1993

Aging and sarcopenia Timothy J. Doherty J Appl Physiol 2003

Relazione tra livello di attività fisica e markers infiammatori The MacArthur Studies of Successfull Aging

TerzileSuperiore

IL-6*

TerzileSuperiore

PCR†

OR (95% IC)Livello di attività fisica

Alto livello attività fisicadi svago 0.65 (0.48-0.87) 0.70(0.51-0.95)

Alto livello di attività fisicain casa/giardino 0.90(0.67-1.20) 0.70(0.51-0.96)

Alto livello di attività fisicaDurante il lavoro 1.02(0.76-1.38) 0.99(0.68-1.30)

* dopo aggiustamento per BMI, scolarità, storia di cardiopatia ischemica

† dopo aggiustamento per BMI, scolarità, razza, fumo, storia di cardiopatia ischemica

Reuben DB, 2003

Adulto Sarcopenicosano

0

40

10

20

VO2 m

ax (m

l/Kg-

1 /min

-1)

80% of VO2 max: occurrence of dyspnea

Sarcopenicomalato

Camminareper qualche

isolato

Camminarein casa

Relazione tra modificazioni della VO2 max con l‘invecchiamento e stato funzionale

Roubenoff, 1999

Modificazioni della VO2 max legate all`età e all`attività fisica

Buskirk et al., 1987

20 40 60 80Eta´

VO2 max(ml/Kg-1/min -1)

interventodell`attività fisica

10

30

50

70

AttiviSedentari

Variazioni di peso e composizione corporea dopo 20 settimane di esercizio di resistenza

80

40

20

0

60

PESO %FATFATMASS

FFM

*

**

*

*P<0.05

pre - training post - training

J. H. Wilmore et al., 1999

Kg80

40

20

0

60

%

Variazioni del tessuto adiposo e della sua distribuzione dopo 20 settimane

di esercizio di resistenza

J. H. Wilmore et al., 1999

sottocutaneo

300

200

0

100

cm2 *

*

*

50

1

100

cm

Circ.fianchi

Circ.vita WHR

**

*

visceraleGrasso addominale

totale

*P<0.05

pre - training post - training

Esercizio di resistenza e dispendio energetico basale

8 maschi 4 femmine56-80 anniBMI 26+0.6

12 settimane di esercizio di resistenza

MASSA MAGRA MASSA GRASSA RMR (6.8%)

DOPO PAREGGIAMENTO PER FFM = RMR

W. W. Campbell et al., 1994

Can physical activity attenuate aging-related weight loss in older people? The Yale Health and Aging Study, 1982-1994.

Dziura, Am J Epidemiol 2004

Modificazioni della forza muscolare dopo esercizio di potenza

Exercise Pre-training Post-training

Knee flexion 0.22 + 0.02 0.40 + 0.04*

Right knee extension 0.27 + 0.03 0.42 + 0.03*

Left knee extension 0.26 + 0.03 0.41 + 0.03*

Campbell et al., 1994

*p<0.001

kg/kg FFM

Relazione tra intensita` dell`esercizio e risposta fisiologica nell`anziano

Variazioniforzaquadricipite(%)

175

100

50

0

150

Low Moderate HighTraining intensity

M. A. Fiatarone et al., 1993 (mod)

Aniasson, 1981 Uomini sani(69-74 anni)

No modificazioni area Trasversale muscolare Forza muscolare

Pratley, 1994 4-mesiAltaintensità

FFM, FM 40% forza muscolare

Frontera, 1988 11% area trasversalemetà coscia Forza muscolare

Effetti dell’esercizio su forza muscolare e composizione corporea

3-mesiBassaintensità

Pyka, 1994 Uomini sani(68 anni)

area trasversalefibre muscolari forza muscolare

Fiatarone, 1990

6-mesiAltaintensità

Uomini sani(50-65 anni)

7 mesiAltaintesità

Uomini e donne fragiliistituzionalizzati

2 mesiAltaintensità

2.7% area trasversale metà coscia 113% forza muscolare

Uomini sani(64 anni)

Fiatarone, 1994 (età media 90 anni) 9% area trasversale metà coscia 174% forza muscolare

(72-98 anni)

Mod from Bross, 1999

Probabilità di morire in età avanzata, senza disabilità nell’anno antecedente la morte in relazione al livello di attività fisica

EPESE Study

UominiLow exerciseMedium exerciseHigh exercise

DonneLow exerciseMedium exerciseHigh exercise

% di 65 ennisopravvissutifino a 80 anni(uomini) o 85anni (donne)

% di anzianideceduti in età

avanzatasenza disabilità

% of 65 ennisopravvissutifino a 80 e 85

anni senzadisabilità

344863

475770

434558

223441

152237

101929

Leveille et al. Am J Epidemiol 1999;149:654-664.

0

10

20

30

40

50

60

% d

isab

ility

1st 2nd 3rd

BMI < 25 (n=22)

BMI >= 25 (n=63)

tertiles of physical exercise

(min/week)

(0-420) (421-728) (729-2300)

a

b

Di Francesco, Aging in press

Leisure time physical activity obesity and disability in the Elderly

Bull World Health Organ vol.81 no.11 Genebra Nov. 2003POLICY AND PRATICE

Exercise interventions: defusing the world's osteoporosis time bombKai Ming ChanI, 1; Mary AndersonII; Edith M.C. LauIII

... Walking, aerobic exercise, and t'ai chi are the best forms of exercise to stimulate bone formation and strengthen the muscles that help support bones.

... Encouraging physical activity at all ages is therefore a top priority to prevent osteoporosis

It is clear that exercise late in life, even beyond 90 years It is clear that exercise late in life, even beyond 90 years of age, can increase muscle mass and strength twofold or of age, can increase muscle mass and strength twofold or more in frail individualsmore in frail individuals

...there is convincing evidence that exercise in elderly ...there is convincing evidence that exercise in elderly persons also improves function and delays loss of persons also improves function and delays loss of independence and thus contributes to quality of life...independence and thus contributes to quality of life...

... randomized clinical trials of exercise have been shown ... randomized clinical trials of exercise have been shown to reduce the risk of falls by approximately 25 percentto reduce the risk of falls by approximately 25 percent

Fitness cardio-vascolare Performance cardiaca Picco di riempimento diastolico Contrattilità cardiaca Contrazioni ventricolari premature Capacità aerobicaPA sistolica e diastolicaMiglioramento profilo lipidico ematicoMiglioramento resistenza Benefici legati

all’attività fisica

PesoCorporeo

Tessuto adiposo viscerale Grasso corporeo percentuale Massa muscolare

Osteoporosi declino densità ossea densità ossea

Diabete tipo 2

Tolleranza glucidica HDL LDL e VLDL Trigliceridi

Benesserepsico-fisico

livelli catecolamine, norepinefrina e serotonina Depressione

SistemaMuscolo-

scheletrico Forza, flessibilità Disabilità muscoloscheletrica Rischio cadute Rischio fratture Tempi di reazione

National Blueprint, 2001The RobertWood Johnson Foundation