Sports Medicine

1
Are Current Health Care Practices Propagating
Obesity in our Youth? The Role of the Physician
to Prescribe Solutions Thomas M. Best, MD, PhD,
FACSM The Ohio State University
Improving Peoples Lives through innovations in
personalized health care
Sports Medicine
2
What Motivates Change?

• There is a crisis
• A critical mass of scientific evidence exists
• Shift in social attitude occurs
• Public cynicism grows
• Political pressures begin to build

3
What Motivates Change?

• There are 2 kinds of disease one is
  pathological, the other is political

4
Physical Exercise offers protection against a
cluster of diseases
Type 2 diabetes

Cardiovascular Diseases
Breast cancer
Depression
Colon cancer
Dementia
Pedersen BK. J.Physiology 2009
5
Exercise Deficit Disorder (EDD) in Youth

• Walker GA, Edwards NM, Stracciolini A, Best TM,
  Faigenbaum AD, Myer GD. The Use of
  Exercise-specific V Codes and Reimbursement at a
  Large Pediatric Medical Center. AMSSM 2013.

6
Youth Fitness and Sports Paradox

• Survey of HS seniors
• Less than 25 of boys and 15 of girls exercise
  vigorously .
• Childhood obesity is an emerging epidemic.
• However
• Half the exercising group is actively involved on
  an athletic team, many participating all year.
• Increased risk for orthopedic injury, especially
  related to overuse.

7
Youth Fitness and Sports Paradox

• The Changing Landscape of Playgrounds!
• Most exercise obtained by children in America is
  no longer obtained in physical education class or
  free play it comes through organized youth
  sports.
• Children are less fit and obesity is growing, yet
  so is athletic injury!

8
Physically Inactive kids at greater risk for
injury!

• Study of 995 children aged 9-12 years.
• Low levels of habitual PA have significantly
  increased injury risk.
• The children at highest injury risk are the
  target audience of the contemporary PA promotion
  efforts.
• Therefore, PA promotion should focus on injury
  prevention as well.

Bloemers BJSM 2011
9
Comprehensive Management Strategies for
Management of EDD in Youth
Myer, GD, Faigenbaum, AD, Stracciolini, A,
Hewett, TE, Micheli, LJ and Best, TM (2013).
"Comprehensive Management Strategies for Physical
Inactivity in Youth." Current Sports Medicine
Reports July/August.
10
Why Kids Should Exercise

• Compared to kids who dont exercise, kids who do
• Can run longer and faster
• Have stronger bones
• Have stronger muscles
• Are less likely to be fat
• Have less stress and depression
• Are less likely to develop chronic diseases
• Are more likely to be healthy adults

11
Exercise Helps Prevent

• Diabetes
• Cancer (breast and colon)
• High blood pressure
• Depression
• Osteoporosis
• Alzheimers disease
• Heart attacks
• Dying early

12
Physical Activity Improves Mental Health

• Regular PA may increase self esteem
• Regular PA may decrease anxiety/depression
• Some evidence shows teen girls have lower rates
  of sexual activity and pregnancy when PA
  increased
• Some evidence regular PA associated with
  decreased smoking, alcohol and drug abuse

K.J. Calfas, W.C. Taylor. Ped Exerc Sci 1994.
6406-423 Sabo et al. J Adolesc Health
199925207-16
13
Fitness And Stanford Achievement Test 9th Ed
SAT-9 and Fitnessgram Results

• Fitnessgram test
• 1. Aerobic Capacity
• 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

14
Grade 5SAT 9 and Physical Fitness
353,000 Students
80
70
60
50
SAT 9 Percentile
40
30
20
10
1
2
3
4
5
6
Number of Fitness Standards Achieved
Source California Dept. of Education Study,
December 10, 2002
15
Grade 9SAT 9 and Physical Fitness
279,000 Students
70
60
50
40
SAT 9 Percentile
30
20
10
0
1
2
3
4
5
6
Number of Fitness Standards Achieved
Source California Dept. of Education Study,
December 10, 2002
16
Improvements in Fitnessgram ResultsPE 4 Life
Program at 6 months

• Woodland Elementary School, Kansas City PSDFall
  2005 Spring 2006, Grades 4 and 5

? 60
Modified Sit Reach
Push-Up
? 88
? 127
Paced Curl-Up
Pacer Test (Cardiovascular Fitness)
? 207
? 182
Flexibility Test
? 433
Strength Test
0
10
20
30
40
50
60
70
17
Percent Reduction in Disciplinary IssuesPE 4
Life Program at 6 months

• Woodland Elementary School, Kansas City PSD
  33Fall 2005 Spring 2006, Grades 4 and 5

Discipline Incidents Involving Violence
228

• ? 59

94
Resulting Out-of-School Suspension Days
1177

• ? 67

392
0
200
400
600
800
1200
1000
1400
18
Fitness and Neurocognitive Functionin
Preadolescent Children

• 24 children, mean age, 9.6 years
• Fitness assessed by FITNESSGRAM
• Neurocognitive 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
371967
19
How Much Physical Activity Do Kids Need?

• Children and adolescents should do 60 minutes
  (1 hour) or more of physical activity
  daily.
• Aerobic Activities most should be either
  moderate or vigorous intensity PA. Include
  vigorous-intensity PA at least 3 days per week.
• Muscle-strengthening Activities at least 3 days
  of the week, as part of the 60 or more minutes.
• Bone-strengthening Activities on at least 3 days
  of the week, as part of the 60 or more minutes.
• Activities should be age-appropriate, enjoyable,
  and offer variety.

20
Kids exercise less as they get older
Boys weekday 14.7 yrs
Girls weekend 12.6 yrs
JAMA. 2008300(3)295-305. doi10.1001/jama.300.3.
295
21
of High School Students Meeting Guidelines
Were physically active doing any kind of
physical activity that increased their heart rate
and made them breathe hard some of the time for a
total of at least 60 minutes/day during the 7
days before the survey. Source National Youth
Risk Behavior Survey, 2007.
22
When are elementary school students active?
Steps per day
Morgan CF, et al (2003) Journal of Physical
Education Recreation and Dance, 74(7), 33-38.
23
Chronic Disease in Children

• Pediatrics Nov 08 Number of children
  taking meds for chronic diseases jumped
  dramatically in past 3 years.
• Diabetes 103 increase (kids as young as 5)
• Asthma 47 increase
• ADHD 41 increase
• Cholesterol 15 increase

24
The Freshman 15?

• Studies suggest actual weight gain during 1st
  year of college is
• 6 lbs in men
• 4.5 lbs in women
• What are the causes?
• Not enough exercise
• Poor diet fast food, dormitory food, skipped
  meals
• Poor sleep habits
• Stress

25
Obesity Trends Among U.S. AdultsBRFSS, 1990,
2000, 2010
(BMI ?30, or about 30 lbs. overweight for 54
person)
2000
1990
2010
No Data lt10 1014
1519 2024 2529
30
26
Are patients and their physicians giving up?

• Data from National Ambulatory Medical Care Survey
  for 1995-96 and 2007-08 showed
• During this period, adults who were overweight or
  obese increased from 52.1 in 95 to 63.3 in
  08.
• Patients seen in 2007-08 had 46 lower odds of
  receiving weight counseling than 95-96.
• Patients with hypertension 46 less likely and
  diabetics 59 less likely to receive counseling.
• The campaign on obesity is not working!
• Whats the definition of insanity?

Kraschnewski, et al, Medical Care, 2013
27
We need a new (and fresh) approach!

• We need to give patients permission to be fat,
  and still be healthy!
• Shift focus off of BMI and onto physical
  activity.
• Health At Every Size (HAES)
• Focus on broader health
• 95 regain lost wt. in 3-5 yrs
• Change in BMI is not a success measure for an
  exercise program

28
What can we do?

• Large scale exercise prescription initiative in
  adults and kids
• Every patient Every visit
• Every treatment plan.
• Physical activity should be recorded as a vital
  sign and kids encouraged to do 60 min of exercise
  per day.
• Message should be the same from every medical
  provider.
• We must begin to merge fitness with healthcare.

29
What Can Busy Physicians Do to Encourage Physical
Activity?

• ? 0 Minutes
• Running late? Too many other concerns on the
  patients list? Relax. Perhaps you can discuss
  physical activity at next visit. Hopefully office
  staff will have assessed exercise and provided
  resources.
• ?1 Minute for Advice
• Quickly congratulate kids (and their parents) who
  are getting 420 minutes or more per week of
  moderate-vigorous physical activity.
• Advise patients who are getting fewer than 420
  minutes of the importance of physical activity,
  especially linking benefits to the childs
  complaints, problems and health risks.

30
What Can Busy Physicians Do to Encourage Physical
Activity?

• ?2 Minutes for a Prescription
• Review key messages about the importance of
  physical activity.
• Offer a generic Exercise Prescription.
• Suggest useful ideas (e.g. walk to school, bike
  transportation, active games, after-school
  activity, family fitness activities).
• ?5 Minutes for Brief Counseling
• Assess readiness for change regarding exercise
  habits.
• Ask what the child might want to do to be more
  active and barriers to prevent this from
  happening -- brainstorm on how to get around
  them.
• Explain to parents in detail how exercise affects
  health and development and their child can go
  about incorporating it into their life.

31
Summary

• Youth sports/activity paradox kids are doing
  too much or too little
• The wide ranging benefits of PA in kids and
  adults are well established
• We need to encourage kids to be Healthy at Every
  Size by engaging in regular PA
• Physician have an important role to play in
  promoting PA for health
• An Exercise Vital Sign is an easy way to bring a
  discussion on PA into the exam room
• Even brief advice can have a significant affect