1. Exercise truly is medicine: Key points for the general practitioner Ross Arena, PhD, PT, FAHA Professor and Chief Physical Therapy and Cardiology Division University of New Mexico

2. Outline Why is aerobic fitness so important What we do as clinicians

7. “After adjustment for age and other risk factors, mortality was 13% lower for every 1-MET increase in exercise capacity.”

8. “The age-adjusted reduction was graded and more pronounced in whites than in blacks; each 1- MET increase in exercise capacity yielded 14% and a 19% lower risk for blacks and whites, respectively”

9. CVD Mortality Risk* by Fitness and BMI Categories, 2316 Men with Diabetes, 179 CVD Deaths Church TS et al. Arch Int Med 2005; 165:2114 *Adj for age and examination year p for trend <0.0001 p for trend <0.002

12. CRF and Risk of Incident Hypertension, ACLS Women 4,884 healthy women examined at the Cooper Clinic, 1970-1998 157 women developed hypertension during average follow-up of 5 years Risk adjusted for age, exam year, alcohol intake, smoking, BP, family history of hypertension, waist girth, glucose, & triglycerides Fitness Groups Risk of Developing Hypertension Barlow CE et al. Am J Epidemiol 2006; 163:142-50 P for trend <0.01

15. CRF and Digestive System Cancer Mortality 38,801 men, ages 20-88 years 283 digestive system cancer deaths in 17 years of follow-up CRF was inversely associated with death after adjustment for age, examination year, body mass index, smoking, drinking, family history of cancer, personal history of diabetes Fit men had lower risk of colon, colorectal, and liver cancer deaths High Fit Moderately Fit Low Fit Peel JB et al. Cancer Epidemiol Biomarkers Prev 2009; 18:1111

16. CRF and Breast Cancer Mortality 14,551 women, ages 20-83 years Completed exam 1970-2001 Followed for breast cancer mortality to 12/31/2003 68 breast cancer deaths in average follow-up of 16 years Odds ration adjusted for age, BMI, smoking, alcohol intake, abnormal ECT, health status, family history, & hormone use Odds Ratio p for trend=0.04 Sui X et al. MSSE 2009; 41:742

17. “Following a rigorous screening process, the 33 studies included in the final analysis included more than 100,000 subjects, 6000 all cause mortality events and 4000 cardiovascular events. Each one MET increase in aerobic capacity equated to 13 and 15% decreases in all-cause mortality and cardiovascular events, respectively.”

19. 19 Deaths per Year in U.S. (1,000s) JAMA March 10, 2004 Leading Causes of Death, US 1. Tobacco, 18.1% 2. Poor diet and Physical inactivity, 16.6% 3. Alcohol, 3.5% Actual Causes of Death

20. What can we do about it?

23. An initiative of:

24. 24 Tremendous health benefits are seen with even low levels of exercise. Amount of exercise needed to benefit health is much lower than amount needed for fitness Regular physical activity at the correct intensity: Reduces the risk of heart disease by 40%. Lowers the risk of stroke by 27%. Reduces the incidence of diabetes by almost 50%. Reduces the incidence of high blood pressure, by almost 50%. Can reduce mortality and the risk of recurrent breast cancer by almost 50%. Can lower the risk of colon cancer by over 60%. Can reduce the risk of developing of Alzheimer’s disease by one-third. Can decrease depression as effectively as Prozac or behavioral therapy. Exercise As Medicine

25. 25 U.S. Physical Activity Guidelines AgeNo Chronic ConditionsChronic Conditions Children & Adolescents (6-17) 60 minutes or more of physical activity every day (moderate*- or vigorous**-intensity aerobic physical activity). Vigorous-intensity activity at least 3 days per week. Muscle-strengthening and bone-strengthening activity at least 3 days per week. Develop a physical activity plan with your health care professional. Avoid inactivity. Refer to the Your Prescription for Health series. Adults (18-64) 150 minutes a week of moderate- intensity, or 75 minutes a week of vigorous-intensity aerobic physical activity Muscle-strengthening activities that involve all major muscle groups performed on 2 or more days per week. Develop a physical activity plan with your health care professional. Be as physically active as possible. Avoid inactivity Refer to the Your Prescription for Health series. Older Adults (65+) Follow the adult guidelines, or be as physically active as possible. Avoid inactivity. Exercises that maintain or improve balance if at risk of falling. Develop activity plan with health care professional. Refer to the Your Prescription for Health series. From the 2008 Physical Activity Guidelines for Americans For more information on these guidelines, visit www.acsm.org/physicalactivity. 150 minutes per week of moderate-intensity physical activity Choose your own schedule For example: 30 minutes of moderate-intensity exercise, five days per week OR three 10- minute sessions per day, five days per week

26. 26 Evidence is now overwhelming on the health burden of physical inactivity. The benefits of exercise in the treatment and prevention of chronic disease cannot be denied. We cannot continue to ignore this evidence when formulating treatment plans for our patients. No patient should leave a doctor’s office without an assessment of his/her physical activity and proper prescription of an exercise program, or a referral to a qualified fitness professional.. Summary

27. 27 Initiate a dialogue between every physician and every American. Promote Exercise is Medicine™ in organizations, workplaces and communities. Ensure that exercise is front and center in the national discussion on disease prevention, health and wellness. Large scale exercise initiative led by health care providers: –Every patient; Every visit; Every treatment plan. Physical activity should be recorded as a vital sign. Message should be the same from every provider, regardless of specialty. Call to Action

28. 28 GOALS

29. 29 Exercise Is Medicine™ is a sustainable initiative to: 1.Influence national policy to obtain reimbursement for exercise counseling. 2.Influence medical health record companies to include exercise as a HEDIS measure and health care systems to make exercise a vital sign. 3.Effect policy changes that support physical activity counseling and patient referrals (to health fitness professionals) in clinical settings. 4.Produce an expectation among the public that health care providers should and will ask about and prescribe exercise. 5.Encourage physicians and other health care providers to be physically active themselves. Program Goals For physical activity to become a Vital Sign, with the Physician routinely discussing it with each of their patients. For the Physician to either prescribe appropriate physical activity to each patient or to refer the patient to a qualified health and fitness professional to get a physical activity prescription. For the Public to begin to ask for and expect Physicians to discuss physical activity during each office visit.

30. 30 PROGRAM SPECIFICS

31. 31 Action Guides

32. 32 The Public Action Guide provides you with a simple, fast and effective tool for using exercise as a ‘medicine’ to help prevent or manage many of the most common chronic health conditions. It will also help you approach your health care provider to discuss physical activity as a part of a disease prevention and management strategy. Guide Highlights Meeting the Guidelines and Starting an Exercise Program My Exercise Plan Questions and Answers Exercise is Medicine™ Month Note to Health Care Providers Public Action Guide

33. 33 Follow these guidelines to meet the basic physical activity recommendations after consulting your health care professional. From the 2008 Federal Physical Activity Guidelines for Americans. For more information on these guidelines, visit www.acsm.org/physicalactivity. Meeting the Guidelines and Starting an Exercise Program

34. 34 The first step in meeting any recommendation for how much exercise to do is to simply get started with an activity that will work for you. These tools will help you in assessing your health, figuring out your barriers to exercise and working through some of the challenges to sticking with a program. Pre-Exercise Health Assessment Barriers to Exercise Assessment Exercise Time Finder Cost/Benefit Analyzer … and more! My Exercise Plan

35. 35 Share this resource with your health care provider during your next annual checkup or scheduled visit. Note to Health Care Providers

36. 36 Health Care Providers’ Action Guide Guide Highlights Exercise Prescription and Referral Process document Exercise Readiness and Prescription form Starting an Exercise Program patient handout Your Prescription for Health series Physician office flier The Health Care Providers’ Action Guide provides physicians and other health care providers with a simple, fast, and effective tool for using physical activity, in the right “dosage”, as a highly effective prescription for the prevention, treatment, and management of more than 40 of the most common chronic health conditions encountered in primary practice.

37. 37 1.Determine patient’s current level of activity and willingness to exercise. 2.Determine if patient is fit to exercise independently and what type of fitness professional would be best for referral. 3.Depending on patient’s stage of change, take appropriate action by referring patient to educational material, writing exercise prescription, and/or referring patient to fitness professional. 4.Refer patient to www.ExerciseIsMedicine.org for videos, fliers and resources. Exercise Readiness & Prescription

38. 38 Guide Highlights How to work with health care providers document Introductory letter to health care provider Health and Medical Questionnaire Fitness Assessment Informed Consent Cancellation Policy Starting an Exercise Program handout Your Prescription for Health series The Health and Fitness Professionals’ Action Guide provides health and fitness professionals with a guide for how to work effectively with physicians and other health care providers to use exercise and physical activity, in the correct “dosage”, as a highly effective patient care “prescription.” Health and Fitness Professionals’ Action Guide

39. 39 http://www.exerciseismedicine.org/YourPrescription.htm Provides information and advice on exercising safely with health conditions. Physicians and fitness professionals can recommend these to their patients/clients during visits. Available for download online. Exercising Following Coronary Artery Bypass Surgery Exercising Following a Heart Attack Exercising Following a Stroke Exercising while Losing Weight Exercising with Alzheimer's Exercising with Anxiety and Depression Exercising with Atrial Fibrillation Exercising with Cancer Exercising with Low Back Pain Exercising with Peripheral Arterial Disease Exercising with Visual Impairment “Your Prescription for Health” series

40. 40 http://www.exerciseismedicine.org/PSA.htm The American College of Sports Medicine (ACSM) has partnered with the United States' Office of the Surgeon General to create public service announcements (PSAs) promoting Exercise is Medicine™. The PSAs feature the acting surgeon general, Rear Admiral Steven K. Galson, M.D., M.P.H., and a message encouraging physical activity. Public Service Announcements

41. 41 Additional Resources

42. When you click on the “Exercise Vitals” the section opens up to display the two exercise intake questions that can be completed in a quick manner. The date and time this data was captured will also be noted/stored. Exercise as a Vital Sign Kaiser Permanente

43. Assessing Physical Activity vs. Physical Fitness

45. Conclusions and Need for Future Research “Given the strong evidence linking exercise test findings with risk in asymptomatic subjects, we believe that the next major priority is the design and implementation of large-scale randomized trials to determine whether an exercise screening strategy leads to an improvement in outcomes.”

46. Section on:

47. Questions?