Fitness, Physical Activity Patterns and Health Outcomes

1
Fitness, Physical Activity Patterns and Health
Outcomes

• Jonathan Myers, Ph.D.
• VA Palo Alto Health Care System
• Stanford University

2
5 Tenets on Physical Activity and Health

• Few Americans are physically active enough to
  gain health benefits
• We are not doing an adequate job of incorporating
  physical activity into the health care paradigm
• Physical activity pattern during adulthood/level
  of fitness are more strongly associated with CHD
  and all-cause morbidity/mortality than
  traditional risk markers
• Small investments in activity yield large health
  outcome benefits
• Higher level of fitness/physical activity is
  cost-effective

3
Tenet 1

• Few Americans are physically active enough to
  gain health benefits

4
Minimal recommendations for physical activity
CDC, AHA, ACSM, Surgeon Generals Report

• All Americans should attempt to accumulate 30
  minutes of moderate activity on most, if not all,
  days of the week
• Additional health benefits can be gained through
  greater amounts of physical activity
• 30 minutes daily activity20 to 40 reduction in
  cardiovascular and all-cause morbidity/mortality

5
Percentages of adults engaging in regular
physical activity
20 min/day, 3-5 days/week
SOURCE 1997-2004 National Health Interview
Survey (CDC, 130,000 US adults)
6
Prevalence of Physically Inactive Americans by
Age
SOURCE 1997-2004 National Health Interview
Survey
7
Obesity Trends Among U.S. AdultsBRFSS, 1991,
1996, 2004
(BMI ?30, or about 30 lbs overweight for 54
person)
1985
No Data lt10 1014
1519 2024 25
Source Behavioral Risk Factor Surveillance
System, CDC.
8
Obesity Trends Among U.S. AdultsBRFSS, 1991,
1996, 2004
(BMI ?30, or about 30 lbs overweight for 54
person)
1996
1985
No Data lt10 1014
1519 2024 25
Source Behavioral Risk Factor Surveillance
System, CDC.
9
Obesity Trends Among U.S. AdultsBRFSS, 1991,
1996, 2004
(BMI ?30, or about 30 lbs overweight for 54
person)
1996
1985
2004
No Data lt10 1014
1519 2024 25
Source Behavioral Risk Factor Surveillance
System, CDC.
10
Leading Causes of Death in the US, 1990 vs. 2000
11
Key points

• lt30 of Americans meet the minimal
  recommendations for physical activity
• More than one third of Americans report getting
  no physical activity at all
• The prevalence of obesity has more than doubled
  since 1990
• Deaths due to physical inactivity/poor diet may
  soon exceed tobacco use as the leading cause of
  preventable death (CDC, 2004)

12
Tenet 2

• Were not doing an adequate job of incorporating
  physical activity into the health care paradigm

13
Physician counseling about exercise

• Walsh et al 1999 - 12 of physicians familiar
  with ACSM recommendations for activity
• Fontaine et al 2005 42 of patients ever
  received advice about exercise
• Ma et al 2005 22 of adolescents provided
  exercise counseling during routine physician
  visit
• Mellen et al 2004 Of 137 million physician
  visits, activity counseling provided during 26
  slightly higher with 2 risk factors
• Ma et al 2004 activity counseling provided lt30
  of physician visits
• Tsui et al 2004 activity discussed 16 of
  visits to residents or attending MDs at Emory
• Honda 2004 Of 26,158 physician visits, 24.5
  discussed exercise college educated 75 more
  like to receive exercise advice
• Frank et al 2003 33 of female MD specialists
  counseled patients at least yearly
• Kennedy et al 2003 11.8 of family practice
  MDs counsel most patients in Canada
• Glasgow et al 2001 28 of patients surveyed
  received physician advice to increase activity
  level
• Epel et al 2000 16 received activity advice
  from health care provider visit in Israel
• Stafford et al 2000 32.8 of obese patients in
  NHANES study (56,000 office visits) received
  exercise counseling during physician visit
  (weight loss counseling in 52)
• Wee et al 1999 - Among 9,777 patients who had a
  medical check-up within the last year, 34 of
  physicians discussed physical activity

14
Physician counseling about exercise

• Fontaine et al 2005 42 of patients ever
  received advice about exercise
• Ma et al 2005 22 of adolescents provided
  exercise counseling during routine physician
  visit
• Mellen et al 2004 Of 137 million physician
  visits, activity counseling provided during 26
  slightly higher with 2 risk factors
• Ma et al 2004 activity counseling provided lt30
  of physician visits
• Honda 2004 Of 26,158 physician visits, 24.5
  discussed exercise college educated 75 more
  like to receive exercise advice
• Frank et al 2003 33 of female MD specialists
  counseled patients at least yearly
• Glasgow et al 2001 28 of patients surveyed
  received physician advice to increase activity
  level
• Wee et al 1999 - Among 9,777 patients who had a
  medical check-up within the last year, 34 of
  physicians discussed physical activity
• Walsh et al 1999 - 12 of physicians familiar
  with ACSM recommendations for activity
• Tsui et al 2004 activity discussed 16 of
  visits to residents or attending MDs at Emory
• Kennedy et al 2003 11.8 of family practice
  MDs counsel most patients in Canada
• Epel et al 2000 16 received activity advice
  from health care provider visit in Israel
• Stafford et al 2000 32.8 of obese patients in
  NHANES study (56,000 office visits) received
  exercise counseling during physician visit
  (weight loss counseling in 52)

15
Effect of physician counseling on exercise

• Patients receiving counseling 50 more likely to
  increase physical activity pattern. Kreuter et al
  Arch Fam Med 2000.
• Providing pedometer increased steps walked/day by
  gt2,000, ? stairs climbed, ? days/week walking
  gt30 min, ? frequency of exercise bouts. Stovitz
  et al J Am Board Fam Pract 2005
• Numerous studies have shown that physicians who
  are physically active themselves are more likely
  to counsel patients on the benefits of exercise.
  Frank et al J Am Med Womens Assoc 2003 Abramson
  et al Clin J Sport Med 2000 Wee et al JAMA 1999
• Three sessions of physician-delivered activity
  counseling by phone over 6 months resulted in
  greater physical activity. Green et al Am J Prev
  Med 2002
• Physician-provided exercise Rx, with written
  materials, results in significant increase in
  physical activity over 8 months. Smith et al Br J
  Sports Med 2000
• Activity counseling increased proportion of
  subjects meeting 30 min/5 days/week
  recommendation from 1 2 at baseline to 26 and
  30 in men and women, respectively, at 2 years.
  ACT study, JAMA, 2001
• Project PACE (Provider-based assessment and
  Counseling for Exercise) 3-5 min of counseling
  resulted in 4 times more participation in
  physical activity. Calfas et al. Prev Med 1996.
• Brief, one-time intervention by nurse and
  two-week follow-up phone call resulted in marked
  increases in energy expenditure over 6 weeks.
  Purath et al. Can J Nurs Res 2004.
• Two group counseling sessions increased physical
  activity in sedentary subjects by 70 min/week.
  Brekke et al J AM Diet Assoc 2003
• Training physicians in motivational interviewing
  techniques resulted in 975 kcal/week greater
  energy expenditure among intervention subjects
  over 1-year. Elley et al. BMJ 2003.

16
Effect of physician counseling on exercise

• Patients receiving counseling 50 more likely to
  increase physical activity pattern. Kreuter et al
  Arch Fam Med 2000.
• Providing pedometer increased steps walked/day by
  gt2,000, ? stairs climbed, ? days/week walking
  gt30 min, ? frequency of exercise bouts. Stovitz
  et al J Am Board Fam Pract 2005
• Numerous studies have shown that physicians who
  are physically active themselves are more likely
  to counsel patients on the benefits of exercise.
  Frank et al J Am Med Womens Assoc 2003 Abramson
  et al Clin J Sport Med 2000 Wee et al JAMA 1999
• Three sessions of physician-delivered activity
  counseling by phone over 6 months resulted in
  greater physical activity. Green et al Am J Prev
  Med 2002
• Physician-provided exercise Rx, with written
  materials, results in significant increase in
  physical activity over 8 months. Smith et al Br J
  Sports Med 2000
• Activity counseling increased proportion of
  subjects meeting 30 min/5 days/week
  recommendation from 1 2 at baseline to 26 and
  30 in men and women, respectively, at 2 years.
  ACT study, JAMA, 2001
• Project PACE (Provider-based assessment and
  Counseling for Exercise) 3-5 min of counseling
  resulted in 4 times more participation in
  physical activity. Calfas et al. Prev Med 1996.
• Brief, one-time intervention by nurse and
  two-week follow-up phone call resulted in marked
  increases in energy expenditure over 6 weeks.
  Purath et al. Can J Nurs Res 2004.
• Two group counseling sessions increased physical
  activity in sedentary subjects by 70 min/week.
  Brekke et al J AM Diet Assoc 2003
• Training physicians in motivational interviewing
  techniques resulted in 975 kcal/week greater
  energy expenditure among intervention subjects
  over 1-year. Elley et al. BMJ 2003.

17
Effect of physician counseling on exercise

• Patients receiving counseling 50 more likely to
  increase physical activity pattern. Kreuter et al
  Arch Fam Med 2000.
• Providing pedometer increased steps walked/day by
  gt2,000, ? stairs climbed, ? days/week walking gt30
  min, ? frequency of exercise bouts. Stovitz et al
  J Am Board Fam Pract 2005
• Numerous studies have shown that physicians who
  are physically active themselves are more likely
  to counsel patients on the benefits of exercise.
  Frank et al J Am Med Womens Assoc 2003 Abramson
  et al Clin J Sport Med 2000 Wee et al JAMA 1999
• Three sessions of physician-delivered activity
  counseling by phone over 6 months resulted in
  greater physical activity. Green et al Am J Prev
  Med 2002
• Physician-provided exercise Rx, with written
  materials, results in significant increase in
  physical activity over 8 months. Smith et al Br J
  Sports Med 2000
• Activity counseling increased proportion of
  subjects meeting 30 min/5 days/week
  recommendation from 1 2 at baseline to 26 and
  30 in men and women, respectively, at 2 years.
  ACT study, JAMA, 2001
• Project PACE (Provider-based assessment and
  Counseling for Exercise) 3-5 min of counseling
  resulted in 4 times more participation in
  physical activity. Calfas et al. Prev Med 1996.
• Brief, one-time intervention by nurse and
  two-week follow-up phone call resulted in marked
  increases in energy expenditure over 6 weeks.
  Purath et al. Can J Nurs Res 2004.
• Two group counseling sessions increased physical
  activity in sedentary subjects by 70 min/week.
  Brekke et al J AM Diet Assoc 2003
• Training physicians in motivational interviewing
  techniques resulted in 975 kcal/week greater
  energy expenditure among intervention subjects
  over 1-year. Elley et al. BMJ 2003.

18
Effect of physician counseling on exercise

• Patients receiving counseling 50 more likely to
  increase physical activity pattern. Kreuter et al
  Arch Fam Med 2000.
• Providing pedometer increased steps walked/day by
  gt2,000, ? stairs climbed, ? days/week walking
  gt30 min, ? frequency of exercise bouts. Stovitz
  et al J Am Board Fam Pract 2005
• Numerous studies have shown that physicians who
  are physically active themselves are more likely
  to counsel patients on the benefits of exercise.
  Frank et al J Am Med Womens Assoc 2003 Abramson
  et al Clin J Sport Med 2000 Wee et al JAMA 1999
• Three sessions of physician-delivered activity
  counseling by phone over 6 months resulted in
  greater physical activity. Green et al Am J Prev
  Med 2002
• Physician-provided exercise Rx, with written
  materials, results in significant increase in
  physical activity over 8 months. Smith et al Br J
  Sports Med 2000
• Activity counseling increased proportion of
  subjects meeting 30 min/5 days/week
  recommendation from 1 2 at baseline to 26 and
  30 in men and women, respectively, at 2 years.
  ACT study, JAMA, 2001
• Project PACE (Provider-based assessment and
  Counseling for Exercise) 3-5 min of counseling
  resulted in 4 times more participation in
  physical activity. Calfas et al. Prev Med 1996.
• Brief, one-time intervention by nurse and
  two-week follow-up phone call resulted in marked
  increases in energy expenditure over 6 weeks.
  Purath et al. Can J Nurs Res 2004.
• Two group counseling sessions increased physical
  activity in sedentary subjects by 70 min/week.
  Brekke et al J AM Diet Assoc 2003
• Training physicians in motivational interviewing
  techniques resulted in 975 kcal/week greater
  energy expenditure among intervention subjects
  over 1-year. Elley et al. BMJ 2003.

19
Effect of physician counseling on exercise

• Patients receiving counseling 50 more likely to
  increase physical activity pattern. Kreuter et al
  Arch Fam Med 2000.
• Providing pedometer increased steps walked/day by
  gt2,000, ? stairs climbed, ? days/week walking
  gt30 min, ? frequency of exercise bouts. Stovitz
  et al J Am Board Fam Pract 2005
• Numerous studies have shown that physicians who
  are physically active themselves are more likely
  to counsel patients on the benefits of exercise.
  Frank et al J Am Med Womens Assoc 2003 Abramson
  et al Clin J Sport Med 2000 Wee et al JAMA 1999
• Three sessions of physician-delivered activity
  counseling by phone over 6 months resulted in
  greater physical activity. Green et al Am J Prev
  Med 2002
• Physician-provided exercise Rx, with written
  materials, results in significant increase in
  physical activity over 8 months. Smith et al Br J
  Sports Med 2000
• Activity counseling increased proportion of
  subjects meeting 30 min/5 days/week
  recommendation from 1 2 at baseline to 26 and
  30 in men and women, respectively, at 2 years.
  ACT study, JAMA, 2001
• Project PACE (Provider-Based Assessment and
  Counseling for Exercise) 3-5 min of counseling
  resulted in 4 times more participation in
  physical activity. Calfas et al. Prev Med 1996.
• Brief, one-time intervention by nurse and
  two-week follow-up phone call resulted in marked
  increases in energy expenditure over 6 weeks.
  Purath et al. Can J Nurs Res 2004.
• Two group counseling sessions increased physical
  activity in sedentary subjects by 70 min/week.
  Brekke et al J AM Diet Assoc 2003
• Training physicians in motivational interviewing
  techniques resulted in 975 kcal/week greater
  energy expenditure among intervention subjects
  over 1-year. Elley et al. BMJ 2003.

20
Key points

• Physical activity is not a standard part of the
  health care paradigm
• During a typical visit to a health care provider,
  physical activity is (mentioned, discussed,
  counseled) between lt10 and 30 of the time
• Brief activity counseling results in increases in
  daily energy expenditure
• Physicians are the most influential source of
  advice for matters of healthful behaviors

21
Tenet 3Physical activity pattern during
adulthood/level of fitness are more strongly
associated with CHD morbidity/mortality than
traditional risk markers

• Tenet 4
• Small investments in activity yield large health
  outcome benefits

22
Physical fitness and all-cause mortality A
prospective study of healthy men and womenBlair
SN, Kohl HW, Paffenbarger RS. JAMA 262 2395, 1989

• 10,244 men and 3,120 women
• Maximal exercise testing performed as part of
  preventive medical evaluation
• Mean follow-up gt8 years
• End point all-cause mortality

23
Rates and Relative Risks of Death Among 10,244
Men and 3,120 Women, by Gradients of Physical
Fitness
Age-adjusted. Quintiles of fitness
determined by maximal exercise testing. p
value for trend 0.05.
From Blair SN, Kohl HW, Paffenbarger Jr.RS, et
al Physical fitness and all-cause mortality
A prospective study of healthy men and women.
JAMA 2622395-2401, 1989
24
Exercise Capacity and Mortality Among Men
Referred for Exercise TestingMyers et al. New
Engl J Med 346 793, 2002

• 6,213 consecutive men referred for exercise
  testing for clinical reasons
• 3,679 classified as having cardiovascular
  disease 2,534 normal
• Mean 6.2 years follow-up
• Endpoint all-cause mortality

25

• Exercise capacity most powerful predictor of risk

• 12 reduction in mortality per MET achieved

Myers J, et al. New Engl J Med 346 793, 2002
26
Incremental Survival Benefit per MET

• 1 METresting metabolic rate (3.5 ml O2/kg/min)
• Exercise capacity commonly expressed in multiples
  of the resting metabolic rate (mean peak METs at
  the VA 7-8)
• 2.5 grade on the treadmill, 25 watts on cycle
  ergometer
• 5 METs is upper limit of ADLs
• lt5 METs achieved high risk gt10 METs low risk

27
Incremental Survival Benefit per MET
28
Key Points

• Fitness is inversely and independently associated
  with cardiovascular and all-cause morbidity and
  mortality
• Small increments in level of fitness are
  associated with considerable reductions in
  mortality

29
Physical Activity Pattern as an Independent Risk
Factor for CVD and All-Cause Mortality

• Physical activity and physical fitness are
  related but different entities Physical
  activity A behaviorPhysical fitness An
  attribute

30
Energy expenditure expressed in kcals

• 1 kcal (calorie) energy required to increase 1
  kg water 10 C
• 30 minutes of walking 150 kcals
• CDC/ACSM/Surgeon Generals Report recommendation
  is roughly 1,000 kcals/week
• 30 minutes of brisk walking burns the calories in
  1 plain donut (185 kcals), 1 hour for a glazed
  donut

31
Rates and Relative Risks of Death Among Harvard
Alumni by Patterns of Physical ActivityPaffenbarg
er, Hyde, Wing, et al. Some interrelations of
physical activity, fitness, health, and
longevity. In Bouchard Physical Activity,
Fitness, and Health, Champaign Human Kinetics
32
2000 kcal/week

• Moderate activity (walking) 1 hr/day
• Higher intensity activity, 1 hr, 3-4 times/week
• 6,000 steps/day (pedometer)
• 20 to 25 MET-hours (5 MET activity, 1 hour, 5
  times/week)

33
gt2000 kcal/week
Survival
No activity reported
Follow-up (years)
Kaplan-Meier survival curve for subjects
reporting no recreational activity and gt2000
kcal/week
34
Age-adjusted multivariate predictors of mortality
among clinical variables, physical activity
patterns, and exercise test responses
Other variables included in the model blocks
walked-flights of stairs climbed/week, history of
CHF, exercise induced ventricular arrhythmias,
pulmonary disease, left ventricular hypertrophy,
lifetime occupational activity/week, last year
recreational activity/week, family history of
CAD, age.

Myers et al. Am J Med 117 912-918, 2004
35
More active individuals are at lower
cardiovascular risk (2000-2005)

• Framingham Heart Study
• Aerobics Center for Longitudinal Research
• Honolulu Heart Study
• Canada Health Survey
• Harvard Alumni Health Study
• Copenhagen Male Study
• Zutphen Elderly Study
• Osteoporotic Fractures Research Group
• Caerphilly Wales Study
• Puerto Rico Heart Health Program
• Nordic Research Project on Aging (NORA)
• Swedish Annual Level of Living Survey (SALLS)

• Finnish Twin Study
• Lipid Research Clinics Follow-up Study
• Belgian Physical Fitness Study
• Physicians Health Follow-up Study
• Nurses Health Study
• VA Health Care System
• The Whitehall Study
• Seven Countries Study
• National Center for Chronic Disease Prevention
  and Health Promotion, CDC
• The SENECA Study
• Baltimore Longitudinal Study on Aging
• Womens Health Initiative Observational Study

36
Physical activity vs. physical fitness and
morbidity/mortality from cardiovascular and
all-causesWilliams, Med Sci Sports Exerc 33
754, 2001

• 30 physical activity studies, 1975 to 2001 gt two
  million person-years follow-up
• 8 physical fitness studies, 1983 to 2001
  gt300,000 person-years follow-up

37
Baseline risk
0.9
0.8
0.7
0.6
Risk Reduction
0.5
0.4
0.3
Williams, meta-analysis, MSSE 200133754
30 activity cohorts (gt2 million person-yrs)
0.2
8 fitness cohorts (317,908 person-yrs)
0.1
High Fitness/Activity
Low Fitness/Activity
0
0
20
40
60
80
100
Percentile Activity/Fitness level
38
Key Point

• Physically active individuals have lower
  all-cause and cardiovascular death rates
• 60 to 85 of the world population from both
  developed and developing countries - is not
  physically active enough to gain health benefits
  (World Heart Federation/CDC)

39
What are some clinical applications of measuring
fitness/activity?

• Meta-analyses of exercise participation in
  post-MI/CHF patients
• Effect of training on coronary/peripheral
  endothelial function

40
Meta-analyses of exercise participation in
post-MI/CHF patients
41

• OLDRIDGE ET AL. META-ANALYSIS OF CONTROLLED
  EXERCISE TRIALS FOLLOWING MI (1988)
• 10 randomized trials comprising 4,347 patients
• EVENTS/ OF PATENTS
  ODDS RATIO
• Treatment Control (95 CI) P
• All-cause death 236/1823 (12.9) 289/1791
  (16.1) 0.76 (0.63-0.92) 0.004
• Cardiovascular death 204/2051 (9.9) 252/1993
  (12.6) 0.75 (0.62-0.93) 0.006
• From Oldridge NB, Guyatt GH, Fischer ME, Rimm
  AA. Cardiac rehabilitation after myocardial
  infarction. Combined experience of randomized
  clinical trials. JAMA 260945950. 1988
• TAYLOR ET AL. META-ANALYSIS OF CONTROLLED
  EXERCISE TRIALS (2004)
• 48 trials comprising 8,940 patients
• EVENTS/ OF PATENTS
  ODDS RATIO
• Treatment Control (95 CI) P

42

• ExtraMATCH Study Meta-Analysis of Exercise
  Trials in Chronic Heart Failure
• 9 randomized trials comprising 801 patients
• Events/ of patients
  Hazard ratio
• Treatment Control (95 CI) P
• All-Cause Death 88/395 (22) 105/406
  (26) 0.65 (0.46-0.92) 0.01
• Death/Hosp 127/395 (32)
  173/406 (43) 0.72 (0.56-0.93) 0.01
• Piepoli et al. Exercise training
  meta-analysis of trials in patients with chronic
  heart failure. BMJ 328189, 2004
• Smart and Marwick Meta-Analysis of Exercise
  Trials in Chronic Heart Failure
• 81 Trials between 1966 and 2003
• Events/ of patients
  Hazard ratio
• Treatment Control (95 CI) P

43
Effect of training on coronary/peripheral
endothelial function
44
Could exercise affect coronary blood flow?3
potential mechanisms

• Direct regression of atherosclerotic lesions
• -Shown in animals since the 1950s small
  changes shown in humans with intensive risk
  reduction and statins independent effects of
  exercise unknown
• Formation of collateral vessels
• -Has not been demonstrated in humans
• Change in the dynamics of epicardial flow via
  flow-mediated or endogenous stimuli of the vessel
• -Endothelial function improves markedly with
  exercise

45
Effect of exercise on coronary endothelial
function in patients with coronary artery
diseaseHambrecht et al. N Engl J Med
342454-460, 2000

• 19 patients with CAD and coronary endothelial
  dysfunction randomized to trained or control
  groups
• Trained group performed daily exercise sessions
  under supervision for 4 weeks
• Changes in coronary vascular diameter and flow
  velocity in response to acetylcholine assessed by
  quantitative angiography

46
Exercise Training Group
Effect of exercise on coronary endothelial
function in patients with coronary artery
disease. Hambrecht et al. New Engl J Med 342
454-460, 2000

• 48 change in coronary blood flow in response to
  acetylcholine infusion before and after exercise
  training
• Similar changes in coronary artery peak flow
  velocity and coronary artery reserve (the ratio
  of peak to resting flow velocity)
• One month of exercise training markedly
  improves endothelial-dependent vasodilation in
  patients with CAD

Change in Coronary Blood Flow ()
Control Group
Initial Study
Follow-up at 4 wks
47
Exercise training and endothelial function in
patients with coronary artery disease

• Hambrecht R, Wolf A., Gielen S, et al Effect of
  exercise on coronary endothelial function in
  patients with coronary artery disease. New Engl J
  Med 342454-460, 2000.
• Hambrecht R, Fiehen E, Weigl C, et al Regular
  physical exercise corrects endothelial
  dysfunction and improves exercise capacity in
  patients with chronic heart failure. Circulation
  982709-2715, 1998.
• Edwards DG, Schofield RS, Lennon SL, et al
  Effect of exercise training on endothelial
  function in men with coronary artery disease. Am
  J Cardiol 93617-620, 2004.
• Gokce N, Vita JA, Bader DS, et al Effect of
  exercise on upper and lower extremity endothelial
  function in patients with coronary artery
  disease. Am J Cardiol 90124-127, 2002.
• Moyna NM, Thompson PD. The effect of physical
  activity on endothelial function in man. Acta
  Physiol Scand 180113-123, 2004.
• Vona M, Rossi A, Capodaglio P et al. Impact of
  physical training and detraining on
  endothelium-dependent vasodilation in patients
  with recent acute myocardial infarction. Am Heart
  J 1471039-1046, 2004.
• Hambrecht R, Adams V, Erbs S, et al. Regular
  physical activity improves endothelial
  dysfunction in patients with CAD by increasing
  phosphorylation of endothelial nitric oxide
  synthase. Circulation 1073152-3158, 2003
• Walsh JH, Bilsborough W, Maiorana A. Exercise
  training improves conduit vessel function in
  patients with CAD. J Appl Physiol 9520-25, 2003

48
Tenet 5Higher level of fitness/physical
activity is cost-effective
49
Health care costs and exercise capacityWeiss JP,
Froelicher VF, Myers J, Heidenreich PA. Chest
126608-613, 2004

• 881 consecutive patients referred for exercise
  testing over 2-years
• Costs determined from VA Decision Support Systems
  Network (DSS), providing data costs, patterns of
  care, outcomes, and clinician workload details of
  specific patient encounters
• Age-adjusted costs compared for clinical,
  historical and exercise test responses

50

• 6 ? in cost per MET
• Least fit group 2x cost of most fit group

One Year Cost
METS
51

• 10 cost difference active vs. inactive
• 1 reduction per kcal/week

52
Physical activity is associated with lower health
care costs

• 6 reduction in one-year health care costs per
  tertile of activity. JACC 4516A, 2005
• 6 reduction in health care costs per MET
  achieved. Chest 126608-613, 2004
• Annual reduction of 450 in cost if obese adopted
  3x week activity. Wang et al. J Occup Environ
  Med 46428, 2004
• Increase in activity from 0-1 to 3x per week had
  2,202 decline in annual health care costs.
  Martinson et al. Prev Med 37319, 2003.
• Walking gt60 min/day associated with 12 lower
  total health care costs vs. lt30 min/day. Tsuji et
  al Int J Epidemiol 32809, 2003
• Each additional day of physical activity
  participation yields 4.7 reduction in health
  care costs. Pronk et al. JAMA 2822235, 1999
• Total direct cost of physical inactivity in the
  US 24 billion inactivity and obesity account
  for 9.4 of national health care expenditures.
  Colditz et al. Med Sci Sports Exerc 31S663-S667,
  1999
• 5.6 billion would be saved annually if 10 of
  adults began a regular walking program. Jones TF,
  Eaton CB. Arch Fam Med 3703-710, 1994
• 10,000 participants initiating 2x weekly exercise
  program would prevent 76 deaths and 230 cardiac
  events, resulting in cost savings 1.2 million.
  Munro et al. J Public Health Med 19397-402, 1997
  

53
Key pointPhysical activity is associated with
lower health care costs
54
Summary

• Few Americans are physically active enough to
  gain health benefits
• 30 meet the minimal recommendations for
  activity
• Sedentary lifestyle is a major health problem
  increasing physical activity should be a standard
  part of medical management
• Exercise is discussed between lt10 and 30 of
  health care encounters
• Moderate activity associated with 20-40
  improvements in health outcomes
• Physical fitness/physical activity pattern are
  more powerful markers of risk than commonly
  appreciated
• The least fit stand to benefit the most from
  improving fitness
• As much as half the benefit occurs between the
  least fit and the next fit category
• In patients with existing CV disease,
  rehabilitation programs reduce mortality
• 20 to 30 reductions in CV and all-cause
  mortality
• Incorporation of modest amounts of physical
  activity results in lower health care costs
• 1 per kcal energy expenditure/week