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, GWUMC
Past President, AAPSM

Thursday, February 14, 13

Physics of Exercise
E = MC2

Exercise yields:
Musculoskeletal Fitness
Cardiovascular Fitness
Optimal Body Composition
Fitness 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 Rx
ACSM/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
Osteoporosis Hypertension

Obesity Sarcopenia
Lean Body Mass
Anxiety
Alzheimers
BMI
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 & Evolution
Among 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 & Now
Survival Support for joint activity

Cooperative hunting Exercise groups

Protection of group Marathon training

Share food Weight loss

Social Skills Help You Get
Facebook
a Date with Your Favorite
Twitter Mate

Message boards Males compete

Groups: Red Carpet Female selects

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


Look Backwards While Leaping Ahead

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


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 Length
Tick-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


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


Correlates of brain size in primates

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

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

NCEP Definition WHO Definition
At least 3 of the following: Hyperinsulinemia (upper quartile of
• Fasting plasma glucose ≥110 mg/dL nondiabetic) or fasting glucose
≥ 110 mg/dL AND at least 2 of the
• Abdominal obesity: (waist) following:
• men: > 40” women: > 34.5” • Abdominal obesity:
• Serum TG ≥ 150 mg/dL (1) waist-to-hip ratio, men > 90 cm and
• Serum HDL-C, men < 40 mg/dL women > 85 cm or BMI ≥ 30 kg/m2; or
women < 50 mg/dL (2) waist girth ≥ 94 cm
• Dyslipidemia: Serum TG ≥ 150 mg/dL,
• Blood Pressure ≥ 130/85 mm Hg or
HDL-C, men < 35 mg/dL and women <
medication
39 mg/dL
• Blood Pressure ≥ 140/90 mm Hg or
medication
Lakka H-M, et al. JAMA. 2002;288:2709-2716.
NCEP ATP III. Circulation. 2002;106:3143-3421.
(National Cholesterol Education Program)


Diagnosis of The Metabolic Syndrome
3 of the following are needed for diagnosis:
Risk Factor Defining Level
Abdominal obesity Waist circumference
– Men > 102 cm (> 40 in)
– Women > 88 cm (> 35 in)

Triglycerides ≥ 150 mg/dL
HDL cholesterol
– Men < 40 mg/dL
– Women < 50 mg/dL
Blood pressure ≥ 130/85 mm Hg
Fasting glucose ≥ 110 mg/dL
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.



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



The Insulin Resistance Syndrome
Clinical Manifestations

Central obesity
Glucose intolerance
Hypertension
Atherosclerosis
Polycystic ovary syndrome

Biochemical Abnormalities
Carbohydrate: Lipid: Fibrinolysis:
Insulin resistance High TG Increased PAI-1
Hyperinsulinemia Low HDL-C
Small, dense LDL particles
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
Hyperglycemia

Dysfibrinolysis Hypertension

Macrovascular Insulin Glucose
Disease Intolerance
Resistance

Dyslipidemia Obesity

Endothelial
Dysfunction
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 Death
Adjusted for Age
CHD mortality
4.0 CVD mortality
All-cause mortality
3.5

3.0
Relative Risk

2.5

2.0

1.5

1.0

0.5

0.0
NCEP NCEP WHO WHO
Waist > 102 cm Waist > 94 cm WHR > 0.90 or Waist > 94 cm
BMI ≥ 30
†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)

Component Recommendation
üLDL-raising nutrients
• Saturated fats Less than 7% of total calories
• Dietary cholesterol Less than 200 mg/day
üTherapeutic options for LDL lowering
• Plant stanols/sterols 2 g per day
• Increased viscous (soluble) fiber 10−25 g per day
üTotal calories Adjust caloric intake to maintain
desirable body weight/prevent
weight gain
üPhysical activity Include enough moderate
exercise to expend at least 200
kcal per day

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


Benefit of Treating The Metabolic Syndrome:
Finnish Diabetes Prevention Study

25%

20%
• After 4 years,
risk of diabetes 15%
reduced by 58%
10%

5%

0%
Intervention Control
With Diabetes (%)

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


Modern Hunter-Gatherer
Life Habits
NEW STUDY: JULY 2009
Archives 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


Chronic Diseases Should Be Mostly Avoidable
Atherosclerotic 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)


Reduce risk of CHF by 50%: JAMA JULY 2009

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
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, MPH
JAMA. 2009;302(4):394-400.


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

>20%
JULY 2009

10%

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

Copyright restrictions may apply.


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


Cumulative survival and exercise capacity

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

Copyright ©2008 American Heart Association


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 disease

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 10x

United States 31.1 33.2

U.S. tops the scales of large countries.

66%
Obese or Overweight


66%
Obese or Overweight

By 2015 - 75% Overweight
41% 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. Adults
BRFSS, 1985

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


Obesity* Trends Among U.S. Adults
BRFSS, 2003
(*BMI ≥30, or about 30 lbs overweight for 5’4” person)

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

Source: Behavioral Risk Factor Surveillance System, CDC


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


Pillars of Fitness

Cardiovascular

Musculoskeletal

Physiological


Achieving Fitness

“Cardio”

Resistance / Strength Training

Healthy Eating

Motivation - The sometime missing factor


Next Action List
Remember 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
Or
Cable Low Row

Pulldown


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 Bridges

Pushups 5 - 15 1 - Legged Bridges

Jumping Jacks - Split Squat
40-50
Reverse Crunch
Planks - Hold 20-45
Pull-ups with assist
seconds
Inverted Rows
Side Planks


DB Circuit

DB Lunge - or BW
Walking Lunge - DB - Combo - Fly/DB
15 each side Bench Press
DB Split Squat DB - Bent over Row
DB OH Press DB - Step up
(optional)
( or DB
Combination Squat, Crunches, Planks
Curl, Press)

Balance

Don’t forget balance in training and balance training

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, FAAPSM
Past President, AAPSM
Clinical Assistant Professor of Surgery, GWUMC
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

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