Exercise Is Good For What Ails You

Exercise: Good For What Ails You

Stephen M. Pribut, D.P.M., F.A.A.P.S.M.

Clinical Assistant Professor of Surgery, GWUMCPast President, AAPSM

Thursday, February 14, 13

Physics of ExerciseE = MC2

Exercise yields:Musculoskeletal FitnessCardiovascular Fitness

Optimal Body CompositionFitness Truths:

A body at rest tends to remain at rest.A body in motion hates to stop exercise.


GOALS & TAKE AWAY POINTS

Exercise is “akin” to medicine

Good for what ails you

Give each patient an exercise prescriptions


Exercise RxACSM/HHS

30 minutes moderate x 5 days/w

Or 20 minutes high intensity x 3 days/w

+ 10 min warmup and 5 min cool down

2 days per week strength training


Details, Background

DVD Handout

Website:

drpribut.com/sports

Blog


BIG THINKS

HOW DID WE GET HERE?

ENDURANCE EXERCISE (sustained movement) SPURRED EVOLUTION and BRAIN DEVELOPMENT

EXERCISE IS STILL CRITICAL TO OUR HEALTH

OUR GENOME FUNCTIONS BEST WHEN WE EXERCISE

EVIDENCE POINTS TO LESS CHRONIC DISEASE, INCREASED LONGEVITY, DISEASE COMPRESSION


Evolution In Thought

200th Birth Year Anniversary of Darwin

150th Anniversary of Origin of Species


Replacement of Species

67th Birth Anniversary of Jerry Garcia

Grateful Dead

Old and In The Way


Exercise Is The Answer


Exercise Is The Answer

Obesity

Hypertension

AnxietyAlzheimers

Osteoporosis

Lean Body Mass

BMI

Sarcopenia

Diabetes


Exercise Is A Means To Fitness

Don’t view exercise in isolation

Comprehensive approach needed

Cardiovascular (Aerobic)

Musculoskeletal (Strength)

Flexibility

Physiological (lipid profile, bmi, bone density)


What Me Worry?


Planning


Where did we start?

Down from the trees

Upright posture

Chimp brain

Richer Diet

Years later we sat down


Kind and Gentle View


Modern Reality


Driving Forces of Evolution

Mutations and adaptations

Upright gait

Sustained movement (exercise by choice & necessity)

Tremendous effect on neurochemistry, genome, survivability. Sit still & die

Diet - Fire/Cooking Diversity

Socialization - Successful = Reproduction + Survival


Movement & EvolutionAmong driving forces of evolution

Affects genome, survivability.

Alters brain chemistry

VEGF, BDNF, IGF-1, Increase in CBF

Diet - Fire/Cooking Diversity, protein, Dimorphism diminished.

Socialization - Successful = Reproduction + Survival


Socialization Then & NowSurvival

Cooperative hunting

Protection of group

Share food

Support for joint activity

Exercise groups

Marathon training

Weight loss

Facebook

Twitter

Message boards

Groups: Red Carpet

Social Skills Help You Get a Date with Your Favorite Mate

Males compete

Female selectsThursday, February 14, 13

Groups & Genomics: Pleistocene era 45K ya

Group selection of desirable traits resulting in selection of what genes are passed on

Variety of skills desired by group

“Altruism” in group dynamics and warfare

Rapid spread of tools, ornaments, rituals


Talent & Skills Enhance Value To Others


Developing Skills: Enhance Fitness Pursuits


Feline Grace Is Not Species Limited


(Image: Nat Rev Genet. 2007 Feb;8(2):104-15.)

Look Backwards While Leaping Ahead


Telomeres & Exercise

Short Telomere - Looks like open DS DNA

Compounds degrade cellular contents

Apoptosis and Senescence may be protective mechanisms

Leisure Exercise - longer telomeres

Voluntary Mice Runners - more protection


Aging Telomere LengthTick-Tock Goes The Biological Clock


Banging On The Biological Clock


CREDIT: D. FINNIN/AMNH


Made To Run: The First Runner

Australopithecus afarensis compared to Homo erectus.Credit: Laszlo Meszoly, Harvard U.


Evolution Continues

Evolution is an incomplete and ongoing process.

But we can still look back to the recent past to understand what our current genome is based on.


Exercise & Genetics

Genome of Kenyan Runners

Exercise Genes

Impact of Exercise on Gene Expression


Future Use Of Genomics

Exercise Rx - may not increase VO2 Max in 20%

Exercise Rx - may not increase HDL in 30%

Future - genotype may enable improvement via a personalized Rx.


Adjusting course

Our genes are built for motion

Sitting down causes illness

Kill the predators and live longer

If it didn’t grow - you probably shouldn’t eat it.


HOMO HABILIS

2 MYA

Handy man. Made tools.

Thought to possibly use fire, but not make it.

Found in East Africa

Made Stone Tools


Homo Erectus

1.5 mya

Hunter - Gatherer

Larger Brain

Controlled Fire!

Cooked Food


http://earlyhumans.mrdonn.org/tools.html













































































Development

Sexual Dimorphism in Apes (Females Smaller, different head shape)

Cooking - Female, Controlled Food, Got Enough to Eat

Movement - Running

BDNF, VEGF, Other growth factors. Brain - grew & cross connections


R. I. M. Dunbar et al., Science 317, 1344 -1347 (2007)

Correlates of brain size in primates


In The Beginning:What Did We Eat?

Hunter - Gatherers

Not just nuts and berries

Fish and some meat, but not every day.

Neanderthals - Ate terrestial herbivores


EBM of Fitness


Metabolic Syndrome: Kuopio Ischaemic Heart Disease Risk Factor Study: Modified Definitions

At least 3 of the following:• Fasting plasma glucose ≥110 mg/dL

• Abdominal obesity: (waist) • men: > 40” women: > 34.5”

• Serum TG ≥ 150 mg/dL

• Serum HDL-C, men < 40 mg/dL women < 50 mg/dL

• Blood Pressure ≥ 130/85 mm Hg or medication

Lakka H-M, et al. JAMA. 2002;288:2709-2716.

Hyperinsulinemia (upper quartile of nondiabetic) or fasting glucose ≥ 110 mg/dL AND at least 2 of the following:

• Abdominal obesity: (1) waist-to-hip ratio, men > 90 cm and

women > 85 cm or BMI ≥ 30 kg/m2; or (2) waist girth ≥ 94 cm

• Dyslipidemia: Serum TG ≥ 150 mg/dL, HDL-C, men < 35 mg/dL and women < 39 mg/dL

• Blood Pressure ≥ 140/90 mm Hg or medication

NCEP Definition WHO Definition

NCEP ATP III. Circulation. 2002;106:3143-3421.(National Cholesterol Education Program)


Diagnosis of The Metabolic Syndrome

≥ 110 mg/dLFasting glucose≥ 130/85 mm HgBlood pressure

< 50 mg/dL– Women< 40 mg/dL– Men

≥ 150 mg/dLHDL cholesterol

Waist circumference> 102 cm (> 40 in)> 88 cm (> 35 in)

Abdominal obesity– Men– Women

Defining Level3 of the following are needed for diagnosis:

NCEP ATP III did not find adequate evidence to recommend routine measurement of insulin resistance (eg, plasma insulin), proinflammatory state, or prothrombotic state in the diagnosis of the metabolic syndrome.

NCEP ATP III. Circulation. 2002;106:3143-3421.

Triglycerides

Risk Factor


Causes of The Metabolic Syndrome

• Overweight/obesity• Physical inactivity• Genetics• Closely associated with insulin resistance

− Underlying cause of diabetes− Reduced HDL-C− Elevated triglycerides− Hypertension− Abdominal obesity

NCEP ATP III. Circulation. 2002;106:3143-3421.


The Insulin Resistance Syndrome

Central obesityGlucose intolerance

HypertensionAtherosclerosis

Polycystic ovary syndrome

Clinical Manifestations

Lipid:Carbohydrate:

Biochemical Abnormalities

Fibrinolysis:Insulin resistanceHyperinsulinemia

High TGLow HDL-C

Small, dense LDL particles

Increased PAI-1

Brunzell JD, Hokanson JE. Diabetes Care. 1999;22(suppl 3):C10-C13; Dunaif A. Endocr Rev. 1997;18:774-800; Reusch JEB. Am J Cardiol. 2002;90(suppl):19G-26G.


Insulin Resistance: Critical Defect of The Metabolic Syndrome

InsulinResistance

Dyslipidemia Obesity

HypertensionDysfibrinolysis

Hyperglycemia

EndothelialDysfunction

MacrovascularDisease

GlucoseIntolerance

Adapted from McFarlane SI, et al. J Clin Endocrinol Metab. 2001;86:713-718; Reusch JEB. Am J Cardiol. 2002;90(suppl):19G-26G.


Relative Risk of DeathAdjusted for Age

WHOWHR > 0.90 or

BMI ≥ 30

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

Rel

ativ

e R

isk

CHD mortalityCVD mortalityAll-cause mortality

NCEPWaist > 102 cm

NCEPWaist > 94 cm

WHOWaist > 94 cm

† P < 0.05; * Subjects with metabolic syndrome (n = 106–179) vs subjects without metabolic syndrome (n = 1037–1103). BMI = body mass index; WHR = waist-hip ratio.

Lakka H-M, et al. JAMA.2002;288:2709–2716.


Fitness FAIL

Steep decline in fitness from age 16 to 36

More inactivity

Metabolic Syndrome

Development of Fatness, Fitness, and Lifestyle From Adolescence to the Age of 36 Years.Determinants of the Metabolic Syndrome in Young Adults: The Amsterdam Growth and Health Longitudinal Study.

Isabel Ferreira, PhD; Jos W. R. Twisk, PhD; Willem van Mechelen, MD, PhD; Han C. G. Kemper, PhD; Coen D. A. Stehouwer, MD, PhD

Arch Intern Med. 2005;165:42-48.


Strength Training

Can enhance insulin sensitivity

Increase GLUT4

Myosin heavy chain IIx (MyHC IIx) suppression

Triceps extensions - 8 weeks. High intensity was more effective (60% RM) than low (30%RM)

GJØVAAG, T. F. and H. A. DAHL (2009). "Effect of Training with Different Mechanical Loadings on MyHC and GLUT4 Changes." Medicine & Science in Sports & Exercise 41(1) January 2009.


The Fix: Components of TLC(Therapeutic Lifestyle Change)

üLDL-raising nutrients• Saturated fats Less than 7% of total calories• Dietary cholesterol Less than 200 mg/day

üTherapeutic options for LDL lowering• Plant stanols/sterols 2 g per day• Increased viscous (soluble) fiber 10−25 g per day

üTotal calories Adjust caloric intake to maintain desirable body weight/prevent weight gain

üPhysical activity Include enough moderate exercise to expend at least 200 kcal per day

NCEP ATP III (adult treatment panel). Circulation. 2002;106:3143-3421.

Component Recommendation


Benefit of Treating The Metabolic Syndrome:Finnish Diabetes Prevention Study

• After 4 years, risk of diabetes reduced by 58%

Tuomilehto J, et al. N Engl J Med. 2001;344:1343-1350.

Intervention ControlWith Diabetes (%)

0%

5%

10%

15%

20%

25%


Modern Hunter-Gatherer Life Habits

NEW STUDY: JULY 2009Archives of Int Medicine. Active Commuting and Cardiovascular Disease Risk: The CARDIA Study. Penny PhD; Boone-Heinonen, Janne PhD; Sidney, Steve MD, MPH; Sternfeld, Barbara PhD; Jacobs, David R. Jr PhD; Lewis, Cora E. MD. Arch Int Med Volume 169(13), 13 July 2009, p 1216–1223

N = 2364. Active commuting was positively associated with fitness in men and women and inversely associated with BMI, obesity, triglyceride levels, blood pressure, and insulin level in men.


On The Move: 12 Miles/Day

Out of Africa

Land bridges

12 Miles/Day

70,ooo - 10,000 ya


http://www.phillipmartin.info/clipart


















































































Chronic Diseases Should Be Mostly AvoidableAtherosclerotic Cardiovascular Disease


If you want to live, change your life habits.


Life Habits Medicine Big 4

Healthy Lifestyle Characteristics Among Adults in the United States, 2000 Mathew J. Reeves, PhD; Ann P. Rafferty, PhD Arch Intern Med.

2005;165:854-857.

No smoking

Exercise 5 days per week x 30 mins

5 Fruits/Vegetables each day

Healthy body weight (BMI 17.5 - 25)


Relation Between Modifiable Lifestyle Factors and Lifetime Risk of Heart Failure

Luc Djoussé, MD, ScD, MPH; Jane A. Driver, MD, MPH; J. Michael Gaziano, MD, MPHJAMA. 2009;302(4):394-400.

regular exercise

not smoking

moderate alcohol intake

maintaining normal weight

cereal, fruit, and vegetable consumption were associated with a lower lifetime risk of heart failure in male physicians

Reduce risk of CHF by 50%: JAMA JULY 2009


Copyright restrictions may apply.

Djousse, L. et al. JAMA 2009;302:394-400.

Lifetime Risk of Heart Failure According to Number of Healthy Lifestyle Factors

>20%

10%

JULY 2009


Resistance to Exercise

“Our patients will take rat poison to live longer. Can’t we convince them that exercise is good for them?

Robert Salas, MD Past President ACSM, Interview 2008


Copyright ©2008 American Heart Association

Kokkinos, P. et al. Circulation 2008;117:614-622

Cumulative survival and exercise capacity


Sitting Disease

Independent Risk Factor

Sitting as Causative Agent of Disease

BJSM February, 2009

TV and Obesity, DM

Overweight, Obesity, Sedentary Lifestyle

Major role in chronic diseaseThursday, February 14, 13

Sitting = Death

Millions of years ago as we moved across the continents, we’d cover up to 12 miles per day.

If we sat for more than a few minutes, we might become something else’s lunch.

Our brains evolved with much movement.

Sitting time is an independent risk factor for mortality.

Sitting Time and Mortality from All Causes, Cardiovascular Disease, and Cancer. Katzmarzyk PT, Church TS, Craig CL, Bouchard C Med Sci Sports Exerc 2009 Apr 3


Obesity among OECD nations

Japan 2.9% 3.3

Sweden 10.4 9.5

United States 31.1 33.2

10x

U.S. tops the scales of large countries.Thursday, February 14, 13

66%Obese or Overweight


66%Obese or Overweight

By 2015 - 75% Overweight41% Obese


Increasing Obesity U.S.

Bloating of Nation: more than 65 percent of U.S. adults either overweight or obese.


Obesity Trends* Among U.S. AdultsBRFSS, 1985

Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10.


No Data <10% 10%–14% 15%–19% 20%-24% ³25%

Source: Behavioral Risk Factor Surveillance System, CDC

Obesity* Trends Among U.S. AdultsBRFSS, 2003

(*BMI ≥30, or about 30 lbs overweight for 5’4” person)


Unhealthiest Food in U.S.:

Supersizing Perfection

• Baskin Robbins Large Chocolate Oreo Shake

• 2,600 calories• 135 g fat (59 g saturated)


Genetically Induced Hopelessness?

Genetic FTO (fat mass & obesity related)

Studied N = 704 Old Order Amish

no effect on those with above-average physical activity scores

“the increased risk of obesity owing to genetic susceptibility by FTO variants can be blunted through physical activity”

Rampersaud, E., B. D. Mitchell, et al. (2008). "Physical activity and the association of common FTO gene variants with body mass index and obesity." Arch Intern Med 168(16): 1791-7.


Exercise And The Brain

50% reduction in risk of dementia

Primes brain for learning

Decreases depression

depression with heart disease may be due to decreased ability to exercise

Improved Stroke outcome - milder, recovery

Increase in CBF (up to 60% VO2Max)


“Exercise is like Miracle Grow for the brain”

John Ratey, M.D., Harvard School of Medicine

http://www.youtube.com/watch?v=Bmc0ERKfjP0

“Exercise is like taking Ritalin and a bit of Prozac” (Metaphor Man)






Exercise Improves Learning(by increasing Neuroplasticity)

Vascular bed - increased O2, Glu availability, enhanced waste product removal.

Increased Serotonin, Dopamine, BDNF (Miracle Gro) - strengthen interconnections

IGF-1, FGF, VEGF - Body-brain interaction


Exercise Improves Angiogenesis

Growth factors

Blood flow - CBF Improved (latest studies)

Occurs in skeletal muscle with training. Also brain, heart, and elsewhere.

May enhance healing of ulcers


Exercise Improves Productivity

17% Improvement in productivity after lunchtime exercise (NASA)

Below 60% of VO2Max - increase Cerebral Blood Flow.

Improvement in Algebra test scores


Does increased physical fitness result in increased academic performance?


Results: California Dept. of Education

Higher academic achievement is associated with higher levels of fitness in grades 5, 7, and 9.

Students who meet minimum fitness levels in three or more physical fitness areas show the greatest gains in academic achievement.

Improvement in Algebra test scores


Exercise improves academic performance


Exercise & Depression

Exercise - primary treatment in many countries.

Impact on neurochemistry

Decreases anxiety

Lessens depression

Aging & depression

1.5X increase in depression among sedentary


Yoga

Relaxation

Peace of Mind

Recovery

Low Budget Secret of Russian Success


Russian Drunk Yoga


Cardiovascular

Musculoskeletal

Physiological

Pillars of Fitness


Achieving Fitness

“Cardio”

Resistance / Strength Training

Healthy Eating

Motivation - The sometime missing factor


Next Action ListRemember That “Exercise is medicine”

Give an exercise prescription to your patients

Follow a good exercise program

Make a “Next Action List”

Keep a Journal

Social Media Declarations


10,000 Steps

Rate: 100 Steps per minute = Moderate

Pedometer - measuring aerobic steps


10,000 Steps


Aerobic Fitness Programs

10,000 Steps

HIT

LSD

Biking, Dance, HOT Yoga

Remember to start gently


Exercise Rx

30 Minutes Moderate Intensity x 5 Days/w

or 20 Minutes High Intensity x 3 Days/w

2 Days Strength Training per week

10 - 12 exercises of 10 repetitions

Goal 3 sets of 8-12 reps

Start with 1 set of 15 for 10 exercises


Strength

Body Weight Workouts

DB Workouts

Traditional Mix

HOT Yoga

Pilates


General Concepts of Strength Training

Horizontal Push-Pull

Vertical Push-Pull

Core Body Exercises

Lower Extremity


Old School Workout: Back

Bent Over Rows (DB or BB) (Back - lats)

Lat Pulldown

Cable Low Row

Pulldown

Or


Old School Workout: Arms

Arm Curl (DB or BB) (but note, biceps are worked with the rows in a multijoint and multi-muscle exercise, and curls are not necessary)

Overhead Press (BB or DB)

Optional: lateral raises or front raises

Lying Triceps Pullover


Nostaligic Old School Workout: Chest

Bench Press (BB) Wide Grip (Chest - Pectorals - primary, Triceps - secondary)

Flies (Chest-Pectorals primary, Anterior Deltoid secondary)


Old School Workout: Legs & Abs

Leg Extensions or Leg Press or (cautiously) Squat

Leg Curls

Calf Raise (optional)

Abdominal Crunches


New School Strength Training

Core Strengthening Exercises

Body Weight Routines

Free Weights


Core Circuit

Planks - hold 20 - 60 seconds

Bridge - hold 30 - 60 seconds or repeat 12 times holding 2 seconds each time.

Side Planks - hold 20 - 30 seconds

1 Legged Bridge - repeat 10 times on each side


Core Circuit (2)

Pushups - do 5 - 20+

Prisoner Squats (arms crossed behind your head, not too deep if you have any tendency to knee trouble)

Mountain Climbers - alternating bringing legs forward to your chest.

Bird Dog - On hands and knees - lift and point with opposite arm/hand and leg/foot - hold 5 seconds, repeat 10 times (optional)


Body Weight Circuit

Prisoner Squats - 15

Pushups 5 - 15

Jumping Jacks - 40-50

Planks - Hold 20-45 seconds

Side Planks

Bridges

1 - Legged Bridges

Split Squat

Reverse Crunch

Pull-ups with assist

Inverted Rows


DB Circuit

DB Lunge - or BW Walking Lunge - 15 each side

DB Split Squat

DB OH Press

( or DB Combination Squat, Curl, Press)

DB - Combo - Fly/DB Bench Press

DB - Bent over Row

DB - Step up (optional)

Crunches, Planks


Balance

Don’t forget balance in training and balance trainingThursday, February 14, 13

Metabolic Stirring

Higher intensity circuit workouts

Full body workout

Multiple muscle groups exercised

Craig Ballantyne of Toronto: TT


Success & Fitness

Highly Driven Achievers

Corporate Fitness


Nutrition: Colorful Foods


Start Young: Be Consistent


Exercise Regularly

Eat Healthy

“...teaching an individual to exercise may be better than teaching them to fish...” S. Pribut


Was George Sheehan wrong?

Can you live better, but not longer?

Or can you live healthier than you thought, not have as large a chance of chronic disease, and live longer.

Follow all the tenets of healthy living:

Exercise regularly, don’t smoke, eat lots of vegetables.


Exercise: Good For What Ails You

E = MC2

Stephen M. Pribut, DPM, FAAPSMPast President, AAPSM

Clinical Assistant Professor of Surgery, GWUMChttp://www.drpribut.com


http://www.drpribut.com

http://www.drpribut.com

Words of Wisdom

In theory, there is no difference between theory and practice. In practice there is.

All models are wrong, but some are useful. -George Box


Exercise Is Good For What Ails You

Health & Medicine

Transcript of Exercise Is Good For What Ails You