• Vitamin D & Chronic Disease Riskwith Dr. Michael F. Holick
To view these programs: www.thebeverageinstitute.org
Accreditation
• The Coca‐Cola Company Beverage Institute For Health & Wellness is a Continuing Professional Education (CPE) Accredited Provider with the Commission on Dietetic Registration (CDR) – provider number #BF001. Dietetic professionals (RDs/DTs) will earn 1.0 CE Credit for participating in this program.
• The Preventive Cardiovascular Nurses Association is accredited by the American Academy of Nurse Practitioners as an approved provider of
American Academy of Nurse Practitioners as an approved provider of nurse practitioner continuing education. Provider number: 030602. This program was planned in accordance with AANP CE Standards and Policies and AANP Commercial Support Standards. RNs/NPs will earn 1.25 CE Credit participating in this program.
• Use the MESSAGE box on the left of your screen to submit a question for the Q&A Session
before exiting this program today to access the Course Evaluation andObtain a CPE Certificate.* The CPE LINK will also be provided in a follow‐up email to all participants. Note: if you watched the webinar as part of a group you will be able to obtain a CPE Certificate.
*This program is pre‐approved for CPE for nursing and dietetic professionals. Other professionals may obtain a Certificate of Attendance by emailing [email protected] calling 1‐800‐274‐9390
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Exercise is Medicine: Understanding the Evidence
Continuing Education Program for Nursing & Dietetic Professionals
All professionals welcome – nurses, dietitians, pharmacists etc!
2/5/2010
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Exercise is Medicine (EIM)
ACSM Partners with PCNA to tailor and promote EIM to nurses. ADA recently announced it has also become one of more than 230+ network members participating in EIM.
Today’s webinar is the first of a series of two webinars on EIM.
1. Today EIM Chairman Dr. Robert Sallis will introduce the t i f EIM i l di th i t f h i l ti it
topic of EIM including the impact of physical activity on health and the importance of discussing physical activity at every office visit.
2. April 28th, 2010 ‐Mark Your Calendar for Part 2 ‐‐“Exercise is Medicine: Initiating the Patient Conversation”.
• A webinar‐workshop focusing on EIM case studies utilizing EIM toolkits developed for RNs and RDs for use in clinical settings.
Understanding The Evidence
Guest Speaker
Robert Sallis, MD, FACSM, FAAFP
Department of Family Medicine, Kaiser Permanente Medical Center. Fontana, California
Past President; American College of Sports Medicine
Chair; Science Advisory Committee, California Governor’s Council on Physical Fitness and Sports
Exercise and Health• Physical inactivity has an astonishing breadth
of harmful health implications.• Exercise has a powerful effect on both
treatment and prevention of chronic disease and obesity, as well as premature death.– There appears to be a linear relationship
between physical activity and health status.– The association between disease and an inactive
and unfit way of life persists in virtually every subgroup of the population.
• Physical inactivity is THE major public health problem of our time.
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Lecture Overview• Review sampling of the
proven health benefits from exercise.
• Suggest that Exercise IsMedicine and you should prescribe (and take!) itprescribe (and take!) it.
• Consider merging healthcare and fitness industry with “Sports Medicine” approach.
• Describe EIM initiative –National, state and local.
3 Factors Determine Our Health and Longevity
Behavior
EnvironmentGenetics
Leading Causes of Death in 1900
• Pneumonia/Influenza
• Tuberculosis• Tuberculosis
• Infectious Diarrhea
*All 3 mainly related to environmental factors
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10 Greatest Public Health Achievements – U.S. 1900-1999
• Vaccination• Control of infections• Safer/Healthier foods• Healthier mothers and babies• Safer workplacesSafer workplaces• Motor vehicle safety• Decline in deaths from CAD and
stroke• Family planning• Fluoridation of drinking water• Recognition of tobacco as a health
Deaths per Year in U.S. (1,000s)JAMA March 10, 2004
Leading Causes of
Preventable Death in the U.S.
1. Tobacco, 18.1%
2. Poor diet and Physical inactivity, 16.6%
First generation on pace to NOT out-live their parents
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Are We On Our Way to Extinction? The Sedentary Death Syndrome
The inactivity epidemic is more concerning than the obesity epidemic.
Fitness Vs Fatness
• Better to be fat and fit, than skinny and un-fit.
• Low level of fitness is a bigger risk factor for
li h ildmortality, than mild-moderate obesity.
• Benefits of physical activity are the same, regardless of how much you weigh.
Irrefutable Evidence for Exercise in the 1o and 2o Prevention of:
• Diabetes mellitus
• Cancer (breast and colon)
• Hypertensionyp
• Heart Disease
• Depression
• Osteoporosis
• Dementia
• All-cause and cardiovascular-related death
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Hippocratesfrom his book Regimen; 5th Century B.C.
• “Eating alone will not keep a man well; he must also take exercise. For food and exercise…work together to produce health.”produce health.
• “If it were possible to discover for the constitution of each individual a due proportion of food to exercise with no inaccuracy either of excess or of defect, an exact discovery of health for men would have been made.
Physical Activity at Work and Coronary Artery Disease;
31,000 London Transport Workers
1 2
1.4
1.6
DriversConductors
Rate/1000
0
0.2
0.4
0.6
0.8
1
1.2
Coronary Occlusion Early Mortality*
Conductors
Morris JN et al. Lancet 1953Within 3 days of MI
Death Rates/1000 by Fitness Level; 2135 Men Aged Grouped Men
80
100
120
rate
/100
0 P
Y LowModerateHigh
0
20
40
60
Cru
de d
eath
r
60-69 70-79 80+
Age Groups (years)
Blair & Wei. Am J Health Prom 2000; 15:1-8
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Exercise and Chronic Disease Mortality
Meyers; NEJM; 2002
Fitness and Incident Type 2 Diabetes; 8633 Healthy U.S. Men
4
5
6Diabetes incidence/1000 men
0
1
2
3
Low Mod High
Cardiorespiratory FitnessWei M et al. Ann Int Med 1999
Fitness and Risk of Incident Hypertension 4884 Healthy Women; 5yr follow-up
0.8
1FitnessCategories
Relative Riskfor Hypertension
p for trend <0.01
0
0.2
0.4
0.6 LowModerateHigh
Categories
Barlow CE et al. Am J Epidemiol 2006; 163:142-50Controlled for BMI, age, hx htn
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Physical Activity and Hip Fracture Risk:Nurse’s Health Study; 61,200 Women
0.7
0.8
0.9
1
Adjusted relative risk for hip fracture; Post-menopause
p for trend<0.00155%
0
0.1
0.20.3
0.4
0.5
0.6
<3 3-8.9 9-14.9 15-23.9 24+
Feskanich D et al. JAMA 2002; 288:2300
MET-Hours/WeekControlled for age, BMI, ERT, smoking, diet
Cardiovascular Health Study;Elderly Individuals with CAD
Physical Activity and Mortality
• 1045 women and men ≥65 years with coronary artery disease
• Followed for mortality for 9 yearsFollowed for mortality for 9 years– 489 deaths in 7284 patient years of follow-up
• Physical activity assessed at baseline and at 3 years of follow-up
• Shows dose-response relationship PA and mortality in patients with CAD
Janssen I & Jolliffe CJ. MSSE 2006; 38:418
1
1.25
1.5
1.75
2
Ris
k of
Mor
talit
y
Change in Activity and Adjusted* Risk of Death
0.25
0.5
0.75
-300
0
-250
0
-200
0
-150
0
-100
0-5
00 050
010
0015
0020
0025
00
Change in Energy Expenditure (kcal/wk)
Rel
ativ
e
*Adjusted for baseline activity, age, sex, race, smoking, alcohol, adiposity, comorbidities Janssen I & Jolliffe CJ. MSSE 2006; 38:418
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Relative Benefits of CAD Interventions
• Smoking cessation 60%• Mediterranean diet 65%• Exercise / Wt loss 50%• BP control 42%• Lipid control 25%• ASA for CAD 25%• ASA for CAD 25%• ACE for CHF / MI 22%• B-Blockers for MI 18%• Tight BS in DM2 ?• Control of TG’s / HDL ?• Vitamins 0• HRT 0
Exercise and Dementia in 1740 Women and Men, ≥65 Years (6yr f/u)
0.6
0.7
0.8
0.9
1
Age- and sex-adjusted Hazard ratio for incident
~40% riskreduction
0
0.1
0.2
0.3
0.4
0.5
<3/week 3+/week
Larsen EB et al. Ann Int Med 2006; 144:73-81
Exercise Habits
ratio for incident dementia
Stanford Achievement Test; 9th Edition(SAT-9) and Fitnessgram Results
• Fitnessgram test:1. Aerobic Capacity
2 Body Composition (% of body fat)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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Grade 5; SAT 9 and Physical Fitness353,000 Students
2936
32
4036
4540
50 46
58 55
71
40
50
60
70
80
Per
cent
ile
29 32
0
10
20
30
40
1 2 3 4 5 6
Reading Mathematics
SA
T 9
P
Number of Fitness Standards Achieved
Source: California Dept. of Education Study, December 10, 2002
Grade 7; SAT 9 and Physical Fitness
322,000 Students
2831 32 34
3641
4450
5460
66
40
50
60
70
erce
ntile
2628
0
10
20
30
1 2 3 4 5 6
Reading Mathematics
SA
T 9
Pe
Number of Fitness Standards Achieved
Source: California Dept. of Education Study, December 10, 2002
Grade 9; SAT 9 and Physical Fitness
279,000 Students
3538
28
43
31
51
37
58
45
67
40
50
60
70
erce
ntile
2124
0
10
20
30
1 2 3 4 5 6
Reading Mathematics
SA
T 9
Pe
Number of Fitness Standards Achieved
Source: California Dept. of Education Study, December 10, 2002
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Fitness and Neurocognitive Function in Preadolescent Children
• 24 children, mean age, 9.6 years• Fitness assessed by FITNESSGRAM• Neurocognitive function assessed byNeurocognitive function assessed by
responses to a stimulus discrimination task
• Fitness was positively associated with attention, working memory, response speed, and cognitive processing speed
Hillman CH et al. Med Sci Sports Exerc 2005; 37:1967
The Cost of Inactivity
• Estimated 250,000 premature deaths annually in U.S. attributable to inactivity.
• Medical costs attributed to inactivity in California were estimated at $29 billion yearly in 2005 (32% increase over 5 years)yearly in 2005 (32% increase over 5 years).
• Physical activity and obesity are second only to tobacco use as the leading cause of preventable death in the U.S.– It follows that the “big 3” (exercise, smoking,
BMI) should be assessed at every visit.
Activity Level and Health Claims
• Health claims increase as activity levels decrease.
• Compared to active• Compared to active persons:– Inactive persons
cost $1,543 per year more than active ones.
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Physical Activity and Health BenefitsDose-Response Curve
Dog Walking and Physical Activity in the United States
• National Household Travel Survey asked about dog walking
• 65 million U.S. households with dogs; 39% of households have at least 1 doghouseholds have at least 1 dog– 80.2% of dog walkers took at least 1 walk of ≥10
minutes
– 42.3% accumulated at least 30 minutes of dog walking/day
• 25-40% of dogs are overweight or obese Ham SA, Epping J, Prev Chron Dis April 2006; 3:1-7
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Patient’s deserve to know the facts…
Exercise Is Medicine:
And Everyone Should Take It!
If we had a pill that conferred all the proven health benefits of exercise,
physicians would prescribe it to every patient and our healthcare system would find a way to make sure every patient had
access to this wonder drug.
“Will I still be able to not exercise?”
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What Can be Done?• Nation wide exercise prescription initiative:
– Every patient; Every visit; Every treatment plan.
• Physical activity should be recorded as a vital sign and patients advised to do:
30 i t d t i 5 d k– 30 minutes moderate exercise, 5 days per week.
– Walk, jog, bike etc.
• Message should be the same from every medical provider, regardless of specialty.
• We must begin to merge the healthcare industry with the fitness industry.
Battling Tobacco; A Success Story
• Prior to 1953, doctors appeared in cigarette ads; many smoked.
• Not until late 60’s, did doctors begin to actively counsel quitting.
• 2004 was tipping point; first year ex-smokers outnumbered current smokers.
• It is time for exercise be pushed just as hard.
Goal:
To make physical activity assessment and exercise prescription a standard part of the disease prevention and treatment
paradigm for all patients
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Robert E. Sallis, M.D.(Chair) Sharon Milberger, Sc.D.
Teddy L. Mitchell, M.D. Steve Blair, P.E.D.
Task Force Members
Ralph Bovard, M.D. Russell R. Pate, Ph.D.
Barry A. Franklin, Ph.D. James A. Peterson, Ph.D.,
Melissa Johnson Angela D. Smith, M.D.
Elizabeth A. Joy, M.D. Paul D. Thompson, M.D.
www.Exerciseismedicine.org
Exercise Is Medicine
• A national initiative sponsored by the ACSM and AMA.National launch held• National launch held November 07’ in Washington, D.C.
• Supported by Surgeon General, along with President’s & CA Gov Councils.
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President’s Challenge
U.S. Physical Activity Guidelines
• First ever guidelines for physical activity were released in Oct 08’.
• For Americans age 6 d ld iand older to improve
their health thru activity.– Adults: 150 min per wk of
moderate activity or 75 min of vigorous.
– Kids: 60 min per day
U it d St tUnited States Surgeon General’s Warning
Dr Steven Galson
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Exercise Is Medicine - Italia
• New collaboration between ACSM and Italian Federation of Sport Medicine (FMSI)
Governor’s Challenge to CA Physicians• Gov Schwarzenegger
challenges CA physicians to prescribe exercise to every patient.
• Pledge support on g ppCouncil web-site.– www.CalGovCouncil.org
– Over 3000 Kaiser docs.
– Exercise Rx pad.
• Launch held in May, 08’ in Sacramento.
Governor’s Challenge Press Conference
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“At Kaiser Permanente, we want you to Live well, Be well and Thrive!”
Smith, John M
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Kaiser Permanente – “Thrive”
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Kaiser Permanente – “Thrive”
Summary
• Benefits of exercise in treatment and prevention of chronic disease irrefutable.
• Evidence is overwhelming on the cost and health burden of inactivity.– Exercise is the vaccine needed to prevent– Exercise is the vaccine needed to prevent
chronic disease.
– The “Big 3” (exercise, smoking, BMI) should be addressed at every visit.
– Merge fitness industry with healthcare industry.
• Exercise is an important solution to world health – Exercise is Medicine, and it’s free!
