1. 2. Overweight and obesity
Leading Health Indicators
1. Physical inactivity
2. Overweight and obesity
3. Tobacco use
4. Substance abuse
5. Responsible sexual behaviour
6. Mental health
7. Injury and violence
7. Environmental quality
9. Immunizations
10. Access to health care
Ten Leading Health Indicators that reflect the major health concerns in the US at the beginning of the 21st century were identified
US National Institute of Health 1

2. 2. Overweight and obesity
Leading Health Indicators
1. Physical inactivity
2. Overweight and obesity
3. Tobacco use
4. Substance abuse
5. Responsible sexual behaviour
6. Mental health
7. Injury and violence
7. Environmental quality
9. Immunizations
10. Access to health care
Ten Leading Health Indicators that reflect the major health concerns in the US at the beginning of the 21st century were identified
US National Institute of Health 2

3. Exercise: The miracle cure and the role of the doctor in promoting it
Academy of Medical Royal Colleges UK
Februray 2015

4. Heart Disease 40% Reduction
Two-thirds of the burden of cardiovascular diseases can be attributed to the combination of diet and physical inactivity.
Physical activity has a very strong effect in reducing the development of heart disease.17 Studies vary in quantifying the reduction in risk of heart disease as “up to 50%”, or “ % lower risk” of cardiovascular disease and coronary heart disease.
People who change from doing minimal activity to moderate activity have most to gain.
Across a population, a move to active travel alone could reduce heart disease by 10%.

5. Hypertension
Exercising regularly reduces the risk of ever developing hypertension by 52%.

6. Depresion Depression Lifetime risk 33% 50% Obese Patients Depressed
Risk Reduction General Population30% There is a 20% to 33% lower risk of developing depression, for adults participating in daily physical activity

7. Dementia
30% The evidence is fairly consistent in quoting reduced risks of developing dementia at “20-50%”. 20,35,77,78

8. Bowel Carcinoma 45% Reduction
Physical activity has a very strong effect in reducing the occurrence of bowel cancer
This is quantified at 30-50% lower risk.
The 30 to 50% lower risk of colon cancer in men and women across 19 international studies was related to the beneficial effect of exercise on growth factors and insulin resistance

9. Stroke
30% Reduction
Different reports quote exercise as reducing the risk of stroke or of mortality from stroke by %.

10. Osteoarthritis 50% Reduction
Analysing several studies quantified the reduction in risk of developing arthritis by undertaking moderate exercise at between 22-83%.

11. Risk of diabetes
physical activity is proven to reduce the risk of developing type 2 diabetes by 50-80%.

12. Diabetes – Numbers to Treat for Benefit
6.4 Lifestyle including PA
10 Medication but medication more side effects

13. First 15 Minutes Exercise a day
416,175 people – average follow 8years
3 years increase in Life expectancy
15mins/day - 14% reduction all cause mortality
Every extra 15 mins/day 4% extra < Mortality
Chi Pang Wan et al Lancet Vol Aug 2011

14. Exercise in non-diabetics
Decreases insulin release
Stimulates glucose transport into muscle
Therefore, increase in insulin sensitivity

15. Exercise in non-diabetics
Increases cortisol, catecholamines
Increases glucagon
Free fatty acids and liver glycogen to be mobilized for energy

16. BENEFITS OF EXERCISE Increase insulin sensitivity
Improved functional capacity
Enhanced sense of well-being
Reduced risk of CAD
Reduced risk of MI
Decreased ‘stickiness’ of blood platelets
Reduced risk of High BP
Can reduce high BP
Decreased triglyceride levels
Increased HDL levels
Decreased LDL levels
Improved HDL / LDL ratio
Decreased Body Fat
Decreased risk of Osteoporosis
Decreased risk of Diabetic associated complications

17. Fitness and Incident Metabolic Syndrome;
9007 Men and 1491 Women
Age-Adjusted Rate/1000 45 40 35 30 25 20 15 10 5
p<0.001,each
Low
Middle
High
Men
Women
LaMonte M et al. Circulation. 2005; 112:

18. Fitness and Metabolic Syndrome;
11,833 Patients with 3-Day Diet Records
Odds of Metabolic Syndrome* 1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
Thirds of CRF
Low
Moderate
High
Low intake
High intake
*Adjusted for confounders, including
macronutrient intake
Finley CE et al. JADA 2006; 106:673

19. Fitness and Incident Type 2 Diabetes;
8633 Healthy U.S. Men
Diabetes incidence/1000 men 6 5 4 3 2 1
Low
Mod
High
Cardiorespiratory Fitness
Wei M et al. Ann Int Med 1999

20. Fitness and Incident Type 2 Diabetes;
4747 Japanese Men;
Tokyo Gas Company
Relative risk adjusted for age and risk factors 1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1 I II
III IV
Level of Fitness
Sawada SS et al. Diab Care 2003; 26:2918

21. in 3,757 Men with Metabolic Syndrome
All-Cause Mortality by Fitness Groups
in 3,757 Men with Metabolic Syndrome
Odds Ratio 3
2.5
p for trend <0.001 2
1.5 1
0.5
Low
Moderate
High
Cardiorespiratory Fitness Groups
Katzmarzyk et al. Arch Int Med 2004; 164:1092

22. Risk of cardiovascular disease mortality by cardiorespiratory fitness and body mass index categories, 2316 men with type 2 diabetes at baseline, 179 deaths.
Risk of cardiovascular disease mortality by cardiorespiratory fitness and body mass index categories, 2316 men with type 2 diabetes at baseline, 179 deaths. Risk ratios are adjusted for age and examination year. Black bars = low cardiorespiratory fitness, white bars = moderate cardiorespiratory fitness (in the obese category, the white bar includes both moderate and high cardiorespiratory fitness, and the grey bar = high cardiorespiratory fitness). (Adapted from Church TS et al. Arch Int Med 2005;165:2114–20)‏
Blair S N Br J Sports Med 2009;43:1-2
©2009 by BMJ Publishing Group Ltd and British Association of Sport and Exercise Medicine

23. Mortality in 1744 Men with Diabetes
Fitness and Cancer;
Mortality in 1744 Men with Diabetes
Relative risk of
Cancer Death * 1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
p for trend =0.002
Low
Moderate
High
Cardiorespiratory
Fitness
*Adjusted for age and risk factors
Thompson AL et al. In progress

24. Lifestyle-related Risk Factors and Risk of
Future Nursing Home Admissions; 6462 Adults
RiskFactor
45-64years
HazardRatio(95%CI)
Smoking
1.56( )
Inactivity
1.40( )
BMI≥30.0
1.35( )
HighBP
1.35( )
HighCholesterol
1.14( )
Diabetes
3.25( )
Valiyeva E et al. Arch Int Med ; 166:985

25. Peripheral Neuropathy
brisk 1-hour walk on a treadmill four times a week slowed how quickly their nerve damage worsened

26. Indications for Exercise
Longevity
Quality of Life
Socialization
Weight control
Disease prevention
Disease management
….(I could go on)

28. No Physical Exercise During a 7-Day Period
Men
Women 14 11 21 18 17 27 26 33 37 10 20 30 40
Percent
1988
2002
18-34
35-54
55+
Slan Survey 1999 28

29. Percentage of respondents who reported no exercise in an average week Trend towards inactivity being reversed?

30. Percentage of respondents who reported no exercise in an average week, by age, gender and year (1998, 2002 and 2007)

32. 31% 60% Physical Inactivity is a global priority
Global prevalence of physical inactivity
31%
Irish prevalence of physical inactivity
60%
Has been described as a global pandemic. Globally, a third of adults do not reach public health guidelines for recommended levels of physical activity 3. Ireland is comparably worse than the global picture, with recent surveillance data suggesting that two thirds of our adult populations in physically inactive4.
As Presented by Prof. Fiona Bull, MBE at the NEHRF Expert Symposium in DCU on 19th June, 2014

33. Easy solution, right? Just tell them to exercise more!
I think you’ll find it’s a bit more complicated than that
Ben Goldacre, Science.net

34. Sedentary Behavior and Inactivity Physiology
Killing you softly and gently

35. CC www.TheNounProject.com
Failures to affect our patient’s weight and clinical measurements with exercise therapy. CC

36. Components Activity Thermogenesis Thermal effect of food
2000 Kcal/day
Thermal effect of food
1000 Kcal/day
Basal Metabolic Rate (BMR)
0 Kcal/day

37. Non Exercise Activity Thermogenesis
More detailed!
Exercise
2000 Kcal/day
Non Exercise Activity Thermogenesis
(NEAT)
1000 Kcal/day
0 Kcal/day

38. Which one is more affected by Sedentary behaviors?
Some arguments in favour of NEAT

39. Circulation. 2007;116:

40. Arterioscler Thromb Vasc Biol 2006;26;729-736

41. 8 weeks of low energy diet
20 females, BMI 32
8 weeks of low energy diet
500 kcal x 4w
850 kcal x 4 w
2 groups
Exercise 3/w x 90 minutes
No exercise
Measured Average Daily and Sleeping Metabolic Rates
Department of Human Biology, University of Limburg, Netherlands
Am J Clin Nutr 1995;62:722-9.

42. Am J Clin Nutr 1995;62:722-9.

43. What we thought would happen
Exercise
Exercise
Non Exercise Activity Thermogenesis
(NEAT)
Non Exercise Activity Thermogenesis
(NEAT)

44. What really happened Exercise Exercise
Non Exercise Activity Thermogenesis
(NEAT)
Non Exercise Activity Thermogenesis
(NEAT)

45. Revising concepts is NEAT!
Stable “Exercise” levels
Obesity levels increase
We do “more” with “less”(movement)
NEAT decreases with inactivity.
NEAT decrease may be the main factor in energy overload

46. In cohorts of people who do not exercise
Increased rates of DM
CAD
Obesity
CANNOT BE CAUSED BY ADDITIONAL “EXERCISE”
DEFICIENCY
Diabetes 56:2655–2667, 2007

47. Showing 2 types of muscles, that react very differently to both
Exercise
Lack of movement (Sedentarism)

48. 20 healthy subjects, 5 days of bed rest
Arterioscler Thromb Vasc Biol. 2007;27:

49. Australian Diabetes, Obesity and Lifestyle (AusDiab Study)
173 patient, underwent OGTT
Accelerometer based
Diabetes Care 30:1384–1389, 2007

50. Relationship of sedentarism and
Same population
Relationship of sedentarism and
Waist circumference
3.1 cm difference
Cluster of metabolic risk factors
Diabetes Care 31:369–371, 2008

51. Cross sectional study of 1921 children, Accelerometer based activity
9-10 yold and yolds
Accelerometer based activity
Self reported TV viewing
Metabolic risk score
TV viewing was NOT correlated with PA (r=0.013, p=0.58)
Metabolic risk score: Skin folds, HDL, TG, fasting insulin, FPG
PLoS Med 3(12): e488. doi: /journal.pmed

52. NHANES data from 1999-2000. Metabolic syndrome definition ATPIII
NHANES data from Metabolic syndrome definition ATPIII. Self reported leisure activity time for 43 activities. Self reported screen time
Obes Res. 2005;13:608–614

53. Canadian Fitness Survey Started with 17013 patients
Med. Sci. Sports Exerc., Vol. 41, No. 5, pp. 998–1005, 2009

54. Even if you exercise, the effects are still there!
Active is 7.5 MET/h/wk
Non Exercisers
Exercisers
Even if you exercise, the effects are still there!

55. J Am Coll Cardiol 2011;57:292–9

56. Independent Risk Factors
Times that people spend sitting versus participating in exercise based leisure time physical activity are different classes of behavior with distinct determinants
AND INDEPENDENT RISKS FOR DISEASE
Different effects of sedentary behavior compared to “exercise”
Metabolic and Mortality effects seen
Through age groups
Through ethnic groups
Newer objective data seems to support larger self reported data
Diabetes 56:2655–2667, 2007

57. AusDiab Data
Diabetes Care 31:661–666, 2008

58. IDLE Breaks Study Baker IDI Heart & Diabetes Institute
Effects of acute bout of sitting time in post prandial Glc/Tg
With and Without Breaks

60. Unpublished Data Breaking news: New data
Glucose
Insulin
Mention ABLE study
Breaking news: New data
All are statistically significative!

62. Hot off the presses
Treatment group burns 0.18 kcal/min more (17% more) 300 calories/week
In obese/overweight group, increases to 0.38 kcal/min (32% more) 575 calories/week
Am J Public Health. 2011 Mar 18. [Epub ahead of print]

63. 7 Investments that work for physical activity
Whole-of-school’ programs
Transport policies and systems that prioritise walking, cycling and public transport
Urban design regulations and infrastructure that provides for equitable and safe access for recreational physical activity, and recreational and transport-related walking and cycling across the life course
Physical activity and NCD prevention integrated into primary health care systems
Public education, including mass media to raise awareness and change social norms on physical activity
Community-wide programs involving multiple settings and sectors & that mobilize and integrate community engagement and resources
Sports systems and programs that promote ‘sport for all’ and encourage participation across the life span

64. 64

65. Is there evidence that walking groups have health benefits
Is there evidence that walking groups have health benefits? A systematic review and meta-analysis BJSM Jan 15
What are the new findings?
Outdoor walking groups have wide-ranging health benefits including reducing blood pressure, body fat, total cholesterol and risk of depression.
Outdoor walking groups appear to be an acceptable intervention to participants, with high levels of adherence and virtually no adverse effects.

66. Lifestyle Intervention: Physical Activity Results
74% of volunteers assigned to intensive lifestyle achieved the study goal of > 150 minutes of activity per week at 24 weeks
The DPP Research Group, NEJM 346: , 2002

67. Incidence of Diabetes Placebo (n=1082)
Metformin (n=1073, p<0.001 vs. Placebo)
Lifestyle (n=1079, p<0.001 vs. Metformin ,
p<0.001 vs. Placebo)
Risk reduction
31% by metformin
58% by lifestyle
The DPP Research Group, NEJM 346: , 2002

68. Finnish Diabetes Prevention Study
Intervention goals
5% reduction in initial weight
Exercise ≥30 min/day
Decrease fat to <30% of caloric intake
Increase fibre to ≥15 g per 1000 kcal
Decrease saturated fat to <10% of caloric intake
Cumulative probability of
remaining free of diabetes
Intervention group
Control group
1.2
1.1
1.0
0.9
0.8
0.7
0.6
0.5
0.4 1 2 3 4 5 6
Study year
Tuomilehto et al. N Engl J Med 2001; 344: 1343–50 68

69. Finnish Diabetes Prevention Study
13year follow up Jan 2013
1Year intensive intervention
4 years 58%
7 years 43%
13years 38%
5 Years Delay in onset DM
Cumulative probability of
remaining free of diabetes
Intervention group
Control group
1.2
1.1
1.0
0.9
0.8
0.7
0.6
0.5
0.4 2 3 4 5 6 1
SLtDddddddddddudy year 69

70. Mean Weight Change Placebo Metformin Lifestyle
The DPP Research Group, NEJM 346: , 2002

71. Muscular Strengthening
Exercise large muscle groups
8-12 reps; should fatigue by last rep
Rest 2-3 minutes between exercises
1 set good, 2 sets better
Rest day in between

72. Resistance training prevention diabetes
32002 men – 18 years
150 minutes/week
Resistance Training alone 34% reduction
Aerobic Training alone 52% reduction
Both % reduction
Health Professional follow up study
Arch Intern Med. 2012;172(17): doi: /archinternmed

73. Combined Training HbA1 DMtype2

74. Combined Training DM
The prevalence of increases in hypoglycemic medications were 39% in the control, 32% in the resistance training, 22% in the aerobic, and 18% in the combination training groups with the Mantel-Haenszel test for linear association being significant (P = .005). The prevalence of decreases in hypoglycemic medications were 15% in the control, 22% in the resistance training, 19% in the aerobic, and 26% in the combination training groups (P = .20). The prevalence of individuals who achieved the composite outcome of either decreasing hypoglycemic medication or reducing HbA1c by 0.5% without increasing medications were 22% in the control group, 26% in the resistance training, 29% in the aerobic, and 41% in the combination training group

75. Stress Testing Pre Exercise
Conducting exercise stress testing before walking is unnecessary. No evidence suggests that it is routinely necessary as a CVD diagnostic tool, and requiring it may create barriers to participation.
ADA/ACSM November 2011

76. Pre-exercise evaluation
Cardiac screening is controversial
Decreased risk in DM of unexpected cardiac death who exercise
79% of perfusion abnormalities resolved 3 yrs with medical therapy
If exercise treadmill +, poor prognosis
Don’t know result of interventions
DIAD study
Clin Sports Med 2009;28:379-92
Diabetes Care 2007;30:2892-8

77. Pre-exercise evaluation
Asymptomatic Type II with + adenosine stress compared with non screened
No reduction in cardiac events
High risk Type II revascularization vs aggressive medical therapy
No difference in long term mortality
DIAD study
JAMA 2009;301:
NEJM 2009;360:

78. Stress Testing Vigorous
For exercise more vigorous than brisk walking or exceeding the demands of everyday living, sedentary and older diabetic individuals will likely benefit from being assessed for conditions that might be associated with risk of CVD, contraindicate certain activities, or predispose to injuries, including severe peripheral neuropathy, severe autonomic neuropathy, and preproliferative or proliferative retinopathy

79. Who to do stress test?
Low to moderate intensity, good control, not many risk factors
Start program
Out of shape, starting program
Start low to moderate intensity
OR non-exercise imaging
Out of shape, won’t get as far on exercise test and likely won’t get 85% max HR, test when advancing therapy or if risk factors
Retinopathy, nephropathy, claudication low ABI
Handbook of Exercise in Diabetes 2002
Clin Sports Med 2009;28:379-92

80. Who to do stress test? If moderate to high intensity exercise
AND/OR ADA guideline risk factors
Autonomic neuropathy
PVD, retinopathy
+ EKG
Stress test
OR modify risk factors prior to exercise
Handbook of Exercise in Diabetes 2002
Clin Sports Med 2009;28:379-92

81. FACTORS WHICH PREVENT EXERCISE
READYNESS TO CHANGE
Health concerns
Family commitments
Work commitments
Transport difficulties
Weather
Cost
Security concerns

82. Exercise Type II Exercise reverses deficits in metabolism
Basal insulin
HbA1c
Basal glucose
Liver glucose production
Insulin stimulated glucose uptake
GLUT4 receptors
Insulin sensitivity
Cholesterol, triglycerides
GSSI # ;16(3)

83. Exercise Benefits 20-30% reduction in HbA1c in Type II Decrease lipids
Decrease blood pressure
Weight loss and maintenance
Reduce metabolic syndrome
Reduce risk of CAD !!
HbA1c is with mild disease or intolerance

84. Physical Activity and Mortality DM
Total PA was associated with lower risk of CVD and total mortality.
Compared with physically inactive persons, the lowest mortality risk was observed in moderately active persons:
Hazard ratios were 0.62 (95% CI, ) for total mortality and 0.51 (95% CI, ) for CVD mortality.
Leisure-time PA was associated with lower total mortality risk, and walking was associated with lower CVD mortality risk.
In the meta-analysis, the pooled random-effects hazard ratio from 5 studies for high vs low total PA and all-cause mortality was 0.60 (95% CI, ).
Annals of Internal Medicine Online first August 2012

85. Borg perceived exertion scale
6 No exertion at all 7 Extremely light Very light - (easy walking slowly at a comfortable pace) Light Somewhat hard (It is quite an effort; you feel tired but can continue) Hard (heavy) Very hard (very strenuous, and you are very fatigued) Extremely hard (You can not continue for long at this pace) 20 Maximal exertion

86. Borg perceived exertion scale
Level 1: I'm watching TV and eating bon bons
Level 2: I'm comfortable and could maintain this pace all day long
Level 3: I'm still comfortable, but am breathing a bit harder
Level 4: I'm sweating a little, but feel good and can carry on a conversation effortlessly
Level 5: I'm just above comfortable, am sweating more and can still talk easily
Level 6: I can still talk, but am slightly breathless
Level 7: I can still talk, but I don't really want to. I'm sweating like a pig
Level 8: I can grunt in response to your questions and can only keep this pace for a short time period
Level 9: I am probably going to die
Level 10: I am dead

87. METs 3.5-4 Moderate Walking at a brisk pace (1 mi every 20 min)
Weight lifting, water aerobics
Golf, not carrying clubs
Leisurely canoeing or kayaking
Walking at a very brisk pace (1 mi every 17 to 18 min)
Climbing stairs
Dancing (moderately fast)
Bicycling <10 mph, leisurely

88. METs 4.5-6 Moderately Vigorous Plus Slow swimming Golf, carrying clubs
Walking at a very brisk pace (one mi every 15 min)
Most doubles tennis
Dancing (more rapid)
Some exercise apparatuses
Slow jogging (one mi every 13 to 14 min)

89. Vigorous Exercise Hiking Rowing, canoeing, kayaking vigorously
Dancing (vigorous)
Some exercise apparatuses
Bicycling 10 to 16 mph
Swimming laps moderately fast to fast
Aerobic calisthenics
Singles tennis, squash, racquetball
Jogging (1 mile every 12 min)
Skiing downhill or cross country

90. Why Resistance Training?
Improves metabolism – proven reduction in Insulin Resistance, incidence of D.M., additive effect to aerobic exercise in prevention and treatment of IHD
Improves muscle strength – less falls/#s
Reduced Osteoporosis 1year increase BMD 1.3% Controls loss 1.2%
Arthritis – Reduced pain Improved function

91. Resistance Exercise
Exercise that uses muscular strength to move a weight or move against a resistive load
In diabetes resistance exercise of the major muscle groups on 2 non consecutive days in the week is recommended

92. Resistance Training Resistance can be own body weight
Press Up / Sit Up
Light Weights – Dumb Bells
Resistance bands

96. Progression
Over time and as the person achieves 3 sets of reps the weight can be increased, as this produces impoved blood glucose effects
As the weight increases the number of reps per set can be reduced to 8-10

97. 97