Technology, Networking and Best Practice in Physical Education and Health: Local to Global

Steve Kopecky MD FACC, FAHA, FACP, FASPC Professor of Medicine

Division of Cardiovascular Diseases Mayo Clinic

Role of Physical Activity in Reducing Chronic Disease

Disclosure: Conflict of Interest Stephen L Kopecky

Research Grants NIH/NHLBI Regeneron/Sanofi-Research Grant Amgen – Research Grant

Consultant •Applied Clinical Intelligence: DSMB Chair •Prime Therapeutics – Formulary Committee •Merck- Atherosclerosis Advisory Board

Board of Directors Mayo Clinic Support Services, Texas American Society for Preventive Cardiology, IPP American Society for Men’s Health

How to Prolong a Healthy Life B A S E

Keep <30. Waist < 35” (woman); <40” (man) MI : ctive : Vigorous leisure activity > 2 ½ hours per week moke : Don’t at : 5 Fruits +/or Vegetables per day

How does this help ? Reduces : Dementia, Stroke, Parkinson’s Heart Attack Diabetes, Metabolic Syndrome Arthritis

Reduces : Organ failure & Frailty Death Prolongs : Active, meaningful, and engaged life

How many ways to die are there ?

Patterns of Functional Decline at the End of Life JAMA. 2003;289(18):2387-2392.

Sudden Death Terminal

Illness

Most effective way to avoid Organ Failure and Frailty: •Non-smoking • Regular Vigorous Physical Activity •Eating F/V’s •Ideal Weight

Func

tion

Func

tion

Organ Failure Frailty

“Lack of activity destroys the good condition of every human being, while movement and methodical physical exercise save it and preserve it”.

Plato

There is a positive ‘halo effect’ around starting a physical activity program

Smoking Weight Vigorous Leisure Activity

Stop Lose Start

- Poor eating choices & gain weight - Usually ‘crash’ diets and regain weight - Less smoking, Better eating choices Regular activity is associated with sustained wt loss

Goal Activity Effect

Human body is programmed in such a way that most of its systems (eg, skeletal, muscle, metabolic, and cardiovascular) do not develop and function optimally unless stimulated by frequent physical activity 1

1 Booth et al Reduced physical activity and risk of chronic disease: the biology behind the consequences. Eur J Appl Physiol 2008; 102: 381–90. 2 WHO. Global health risks: mortality and burden of disease attributable to selected major risks. Geneva: WHO, 2009.

Why be physically active ?

Technological revolution – great benefit to many, but a major cost in terms of physical inactivity. In 2009, physical inactivity identified as fourth leading risk factor for non-communicable diseases and accounted for more than 3 million preventable deaths.2

Men

Women

Inactivity

What happens with age ? Inactivity rises with age Who is more active – women or men ?

How physically active are adults worldwide ?

Lancet 2012; 380: 247–57

Worldwide : 31% (95% CI 30·9–31·2) physically inactive

Who is least and most active ? Lowest : SE Asia 17% (16·8–17·2) Highest : Americas and E Mediterranean 43%

Men and is increased in high-income countries

What about the youth ? Proportion of 13–15-year-olds doing <60 min of mod-vigorous physical activity/d is 80% (80·1–80·5); boys more active than girls

Relationship Between Physical Activity and CV Risk

Powell KE, Paluch AE, Blair SN. Physical activity for health: what kind? How much?How intense? On top of what? Annu Rev Public Health 2011;32:349–65.

Highest risk is Physical Inactivity

High aerobic exercise volumes associated with lowest risk

Similar increase in activity yields different risk reductions

J Am Coll Cardiol. 2015; 65(19):2091–100. CRF= cardiorespiratory fitness

assuming constant waist circumference

Level of CRF Overall Hi Mid Low

Age

Tota

l Cho

lest

erol

M

g/dL

Abnormal

95% confidence interval

Trajectories of Total Cholesterol With Aging and Fitness

CRF delays elevated cholesterol by ~15 years

Telomere Length and Risk of MI in Multi-Ethnic Population

D’Mello et al JACC 67(15);19 April 2016, Pages 1863–1865

When telomeres shorten too much, cell division stops

Telomere

Telomere Length and Risk of MI in Multi-Ethnic Population

D’Mello et al JACC 67(15);19 April 2016, Pages 1863–1865

Exercise lengthens telomeres thus reducing MI Risk

Phys Active (>4 hr mod activity/wk vs <4 hr)

Record number of Americans Report Exercising in 2015

Winter = low; Summer = High % Exercising >30+ Min > 3 days/week

Americans exercise more in summer than winter

Source: Behavioral Risk Factor Surveillance System (BRFSS)

People reporting no physical activity in the last month

http://www.cdc.gov/physicalactivity/

2010

http://www.juststand.org/

Sedentary time in adults : Association with DM, CV Disease and

Death

Even if you exercise regularly, high sedentary time increases CV risk

equal to smoking a ½ pack a day

Every 2 hours, get up and walk vigorously for 2 minutes

Diabetologia (2012) 55:2895-2905

What is the relationship between fathers’ and preschool-aged children’s BMI, diet quality, and physical activitya Variable B+/- standard P value error b Total fruit Total vegetables Dairy Weekend activity (total min) Sedentary Moderate intensity Vigorous intensity

a Covariates included father’s race, ethnicity, and income level b Child-related variables as predicted by paternal-related variable

.18+/-.08 0.03

.29+/-.06 <0.0001

.00+/-.07 0.70 .08+/-.08 0.33 .14+/-.39 0.73 .62+/-.18 0.001

Vollmer et al J Acad Nutr Diet. 2015;115:919-926

Clear relationship between fathers’ and children dietary intake and physical activity level

Normal weight father and obese mother : was not a significant predictor of child weight Obese father and normal-weight mother : increased the child’s likelihood for being overweight 4-Fold.

Freeman et al Preventing and treating childhood obesity: Time to target fathers. Int J Obesity. 2012;36:12-15.

Which parents weight and lifestyle most influences a school-aged child ?

At what age does a Child’s Vigorous Physical Activity Correlate with CV Risk later in life ?

Boys Age 2-6 yrs Girls

Age 6-9 yrs

CV

Ris

k Sc

ore

Quintiles of Vigorous Activity (Min/Day) 1 2 3 4 5 1 2 3 4 5

The more vigorous regular activity by age 6-9, the lower CV risk later in life

Jiménez-Pavón et al. BMC Medicine 2013 11:172 doi:10.1186/1741-7015-11-172

What practices reduce the risk for obesity in preschool age children ?

TV/Screen viewing time1 Increased screen time is positively associated with obesity

Shared family meals3 Frequency of shared family meals inversely associated with obesity

1 Int J of Ped Obesity 1(2);103–108:2006 2 J of the Am Dietetic Assoc, 110(7);1049–1057:2010 3 Pediatrics 125 (3);420–428:2010 4 Amer J of Clinical Nutrition 88(6);1459–1468:2008.

Physical activity/active play time2 Physical activity time inversely associated with obesity

Fruit and vegetable consumption4 Higher availability or consumption of fruit +/or vegetables associated w/ lower total energy consumption and body weight and healthier body composition

Screen Viewing Time and Active Play •Am Acad of Pediatrics1 recommends : Children <2 yrs not be exposed to TV Children >2 limited to 1-2 hours of quality programming for TV viewing and screen use •Survey data show that: Watch videos, DVD’s, or TV 2 By 3 months of age, 40% regularly watch Children <2 yrs , 90% watch daily •Early activity patterns persist into childhood 3

1 Barlow Pediatrics, vol. 120, pp. S164–S192, 2007. 2 Zimmerman Archives of Pediatrics and Adolescent Medicine, vol. 161, no. 5, pp. 473–479, 2007. 3 Certain Pediatrics, vol. 109, no. 4, pp. 634–642, 2002.

BMI during Adolescence and Subsequent CV Mortality

Baseline:Age 16-19 yrs n=2,298,130 F/U 42 Mill person-yrs

Cum

ulat

ive

C

V M

orta

lity

(%)

Year of Follow-up BMI >85th %tile in late years

increases risk of early CV death 2-3 fold Twig G et al. N Engl J Med 2016. DOI: 10.1056/NEJMoa1503840

*adjusted for sex, age, birth year, education, socioeconomic status, country of origin, and height

These findings suggest that higher midlife fitness may be associated with the compression of morbidity in older age

Willis et al Arch Intern Med. 2012;172(17):1-8

Does Midlife Fitness Effect the Development of Chronic Conditions in Later Life ?

Bad genes raise heart attack risk by factor 1.3-1.4, Bad lifestyle raises heart attack risk by factor 3-4 !

Chetty et al JAMA. doi:10.1001/jama.2016.4226

Bottom income quartile, 1996-2008

Lighter color = more exercise

Women

Exercise

Lighter color = Longer life span

Life Span

Even in lowest income, life expectancy variation mostly related to behaviors : smoking, obesity, and exercise

Physical Activity vs Cardiorespiratory Fitness

Cardiorespiratory Fitness

Physical Activity

50% increase in ED if your gut is so big you cant see your junk

1 in 3 men in UK can’t see it !

Am Soc for Men’s Health Conference Wash DC 2015 ED=Erectile Dysfunction

We Love Our Health.co.uk commissioned a survey of 1,000 men that

found that because of the size of their bellies, “1/3 of men in Britain age 35-60

years are unable to see their penis" when they stand upright and look downwards.

http://www.digitaljournal.com/article/336489#ixzz3trgF9rio

The "Big Check" campaign : Dr Sarah Brewer, said, "Men care more about maintaining their cars than their own bodies, and often only see the doctor if told to by a female partner or relative."

American Journal of Public Health: September 2015, Vol. 105, No. 9, pp. e54-e59. doi: 10.2105/AJPH.2015.302773

99,791 obese women and 76,704 obese men

BMI (kg/m2) Probability of attaining normal weight 30.0–34.9 40.0–44.9

How often can obese become non-obese ?

If a 5% weight reduction achieved, 80% regain it at 5 years .

Women : 1 in 124 Men : 1 in 210

Women : 1 in 677 Men : 1 in 1290

Cardiorespiratory Fitness

Physical Activity

What reduces CV Risk most : Physical Activity or CV Fitness ?

Williams PT Physical fitness and activity as separate heart disease risk factors : a meta-analysis Med Sci Sports Exerc 2001;33:754-761

CHD= Coronary Heart Disease CVD= CHD plus Stroke

What reduces CV Risk most : Physical Activity or CV Fitness ?

CHD=Coronary Heart Disease CVD=CHD plus Stroke

Williams PT Physical fitness and activity as separate heart disease risk factors : a meta-analysis Med Sci Sports Exerc 2001;33:754-761

Dose response curve for the relative risk of either CHD or CVD

25%

60%

Both beneficial: ‘Fitness’ better than ‘activity’ to reduce CV Risk

Physical Activity : What types help the most ?

There are 4 proven beneficial categories:

*Brisk walking **Jogging-running

2) Muscle-strengthening : > 2 days/week 3) Avoid prolonged sitting : Move for 100 seconds every 30 min (Lowers fasting blood sugar, lowers insulin levels, lowers triglycerides)

1) Aerobic : Mod-Vigorous* ~150 min/week Vigorous** ~ 75 min/week

Point-of-decision prompts

‘I want to climb the stairs to fitness’

Healthy Advertising

www.inudgeyou.com

Social Media Links

Singapore : Bugis MRT Station

PA Education

What does the research tell us about ‘Brain Breaks’ type of activity ?

2-min walking breaks

every 20 min

for 1-2 weeks

5 Hr Postprandial Glucose : After 2-hr of sitting

There is an individual ‘dose response curve’ to activity : More and Intense activity leads to better glucose control

Area

Und

er th

e C

urve

(In

crem

enta

l)

Participant ID

sitting sitting w/ light-intensity activity breaks (RPE 8) sitting w/ mod-intensity activity breaks (RPE 12)

AUC (mmol/L-hr) 6.9 5.3 4.9

Dunstan et al. Diabetes Care 2012;35(5):976–83

What does Fitbit data tell us about motivation* ?

* Eric Friedman FitBit CIO - Personal communication

Number of Steps per day Num

ber o

f ind

ivid

uals

mea

sure

d

0 2500 5000 10000

“If we can find what motivates you, we can get you to be more active”

Examples of Text Messages Used in the TEXT ME Randomized Clinical Trial

Physical Activity : Hi [NAME], don’t forget physical activity is good for you! It reduces your risk of diabetes, heart attack, stroke, and their complications. Walking is cheap. It can be done almost anywhere. All you need is comfortable shoes & clothing.

JAMA. 2015;314(12):1255-1263. doi:10.1001/jama.2015.10945

TEXT ME Randomized Clinical Trial : 6 Month Results

LDL : significantly lower Reductions in : systolic blood pressure and BMI, Tob Increases in : physical activity, Participants reported the text messages to be : useful (91%), easy to understand (97%), and appropriate in frequency (86%).

In patients with coronary heart disease, a lifestyle-focused text messaging service (vs usual care) resulted in a modest improvement in LDL & greater improvement in other CV disease risk factors.

JAMA. 2015;314(12):1255-1263. doi:10.1001/jama.2015.10945

In what year was it shown that there are more people worldwide that are obese (BMI >/=30) than significantly underweight (BMI </= 18.5) ? A 2000 B 2006 C 2016 D Estimated to occur in 2026 E Never been shown

Lancet 2016

We are focusing on drugs to treat , when it would be better to focus on lifestyle to prevent

Atrial Fibrillation = Irregular heart beats

Rahman, F. et al. (2014) Global epidemiology of atrial fibrillation Nat. Rev. Cardiol. doi:10.1038/nrcardio.2014.118

Global Prevalence and estimated increase of Atrial Fibrillation (%) by 2050

Pathak et al JACC 2015;66(9):985-96

Gained < 2 METS

Gained > 2 METS

18%

61%

0%

10%

20%

30%

40%

50%

60%

70%AF Free w/o drugs or ablation

Pathak et al CARDIO-FIT Trial JACC 2015;66(9):985-96

Every MET gained = 9% decline in AF *

*Adjusted for weight loss and BL CRF

Can an improvement in CRF lower Afib Recurrence ?

CRF = Cardiorespiratory fitness AFib= Atrial Fibrillation BL= Baseline

Kaplan-Meier Plot with 95% confidence limits

How much is survival effected by fitness ?

JAMA Submitted

Functional aerobic capacity : 1=<75%, 2= 75%-89%, 3=90%-104%, 4=>105%

Exercise Treadmill Stress Testing

20% Difference

n=12,403

Each increase of 10% in FAC was associated with a decrease in all-cause mortality by 16%

[0.84 (0.82-0.86, p<0.0001)]

Maternal-age-associated risk of congenital heart disease is modifiable

Schulkey et al Nature 520;230-233: 2015

Exercise during pregnancy can help reduce congenital heart defects

VSD= Ventricular septal defect

Public Policy

Family & Social

Networks

Physical &

Social Environs

Community Support

for Healthy Lifestyles

Educators & Schools

Employers & Worksites

Health Plans & Payors

Faith Based Orgs

Building Healthy Lifestyles

to Reduce Chronic Diseases Increased Physical Activity

Improved Nutrition

Decreased Tobacco

Use & Exposure

Decrease Harmful Alcohol

Use

Practical Positive Thinking

Improved Sleep Hygiene

6

8

Requires Personal and Community Efforts

Community Support for Healthy Lifestyles • Individuals - increasingly motivated to adopt/maintain healthy life-styles through community-level initiatives, particularly through employers and worksites • Community supports, in collaboration with the health care system, contribute to healthy lifestyles • All stakeholders should publicly support those measures that promote healthy lifestyles and recommend them to their patients Only these types of interventions are likely to have the

needed impact to engage, motivate and support people to make needed improvements

Brownson RC, Haire-Joshu D, Luke DA. Shaping the context of health: a review of environmental and policy approaches in the prevention of chronic diseases. Ann Rev Public Health 2006;27:341-70.

Increasing physical activity

You cannot overestimate the importance of what you are going

“Never doubt that a small group of thoughtful, committed citizens can change the world…..

indeed, it's the only thing that ever has.”

Margaret Mead American anthropologist 1901-1978

Thank you for your attention !