Dr. Abha Havaldar: Exercise Presentation

EXERCISE: WHAT KIND, HOW MUCH, WHY BOTHER?

Abha Havaldar MD Gastroenterologist St. Joseph, MO

1. Types of Exercise

2. Safety & Risk concerns

Discussion Topics

3. Motivation

4. Intensity & Frequency of Exercise

5. Which Conditions Benefit

1. Types of Exercise

2. Safety & Risk concerns

Discussion Topics

3. Motivation

4. Intensity & Frequency of Exercise

5. Which Conditions Benefit

Endurance

Types of Exercise

Strength

Balance

Flexibility

1. Types of Exercise

2. Safety & Risk concerns

Discussion Topics

3. Motivation

4. Intensity & Frequency of Exercise

5. Which Conditions Benefit

Safety & Risks ACSM: Most people can exercise without seeing a physician first Little evidence supports evaluations prior to exercise Patients with CV, metabolic, or renal disease may need evaluation Too much too fast Omitting warm up and cool down Hydration Electronics in the Outdoors

1. Types of Exercise

2. Safety & Risk concerns

Discussion Topics

3. Motivation

4. Intensity & Frequency of Exercise

5. Which Conditions Benefit

Music can enhance performance & lower perception of fatigue and work Plan exercise into daily calendar Have a workout buddy for accountability

Motivation

Take class or plan an activity event Activity during TV commercials Reward yourself with new workout gear or a massage Activity Tracker

Accurate for step count

Activity Tracker

Overestimates & occasionally underestimates calories burned

1. Types of Exercise

2. Safety & Risk concerns

Discussion Topics

3. Motivation

4. Intensity & Frequency of Exercise

5. Which Conditions Benefit

150-300 min/wk of moderate intensity OR 75-150 min/wk of vigorous intensity

Frequency

30-60 min/day Can be short bursts

Strength training of major muscle groups 2x/wk

Balance & flexibility 2x/wk

Steps

2,600 steps improves CVD risks and early death risks

European Journal of Preventive Cardiology

4,000 steps improves both gray and white matter function and volume

8,800 -10,000 steps may offer more benefits

Can talk but not sing / 3-6 METs / 4-5 Modified RPE (Rate of Perceived Exertion) Walk 4 mph Heavy Clean (wash windows, vacuum, mop)

Moderate Intensity Examples

Push Mower, electric counts Rake Leaves Bicycle 10-12 mph Dance Badminton Doubles Tennis

> 6 METs/ 6-7 Modified RPE (Rate of Perceived Exertion) Walk/Hike/Jog/Run 6mph

Aerobics Class

Vigorous Intensity Examples

Shovel snow

Bicycle 14-16mph

Basketball

Soccer

Singles Tennis

Forget Frequency & Intensity!

Move More, Sit Less

Do what exercise you can

Improve your technique, not volume

Progression is important

Most people can walk 3mph

Every workout does not have to be intense

Stand every waking hour

1. Types of Exercise

2. Safety & Risk concerns

Discussion Topics

3. Motivation

4. Intensity & Frequency of Exercise

5. Which Conditions Benefit

Women may gain greater benefits than men at equal or lower doses of activity

Mortality Risk Reduction Women vs Men 24% vs 18% for aerobic exercise

Gender Differences

Mortality Risk Reduction Women vs Men 19% vs 11% for strength training

Greater survival benefit for women found regardless of frequency, duration and type of exercise

Both sexes get peak survival benefit with 300 min/wk of moderate/vigorous aerobic activity Journal of American College of Cardiology, February 2024

Pregnancy Action: women randomized to 30-60 minutes of aerobic exercise Condition

Risk Reduction

Pre-eclampsia

23%

Gestation DM (activity)

50%

Gestation DM (vigorous activity*)

76%

Obese women had a 31% decrease in gestational DM with exercise

*4.2 hrs/wk

Appetite & Weight Following Exercise Decrease: • Ghrelin – “hunger hormone” • Appetite

Increase: • GLP – decrease gastric emptying , curbs appetite, decrease glucagon if glucose high • PYY – acts to decrease hunger

Appetite & Weight (Long-Term) Decrease: • Fat Increase: • Muscle • Resting metabolic rate • Satiety • Improve response to Insulin and Leptin (prevent hunger)

Sleep If persistently active (>1 hr 2/wk), less likely to report measured insomnia, diminished sleep duration, daytime sleepiness Condition

Risk Reduction

Insomnia

22% less

2 symptoms

40% less

3 symptoms

37% less

Anxiety

Panic Disorder

Exercise decreases anxiety but is less effective than antidepressant

Social Phobia

Exercise + CBT gives added benefit

Unclear what type of exercise or intensity is best

Depression

Exercise offers similar benefits as psychotherapy and medications per meta analysis

Intense exercise is especially effective although light activity offers clinical benefits

• Meta analysis of 218 RCT with 14,700 patients:

Depression

• Moderate decrease in depression for walking, jogging, yoga, strength training, aerobic exercise, tai chi regardless of comorbidities • Effect of exercise was proportional to the intensity

Dementia & Alzheimer's

Physical Activity can decrease:

Suggested exercises:

Risk of Dementia by 28%

20-30 minutes of aerobic exercise

Risk of Alzheimer's by 45%

Brisk walk, cleaning, gardening

Alzheimer’s Society of England

Greater Visceral & SQ fat on MRI of abdomen can predict MRI visualized brain atrophy

Dementia & Alzheimers (Cont’d) Excess fat is bad for the brain Worse if you are a female

Impacts Alzheimer regions of brain

Dementia & Alzheimers • Study of 2000 men x 35 years with healthy behaviors • No smoking, moderate alcohol, healthy weight, healthy diet, regular exercise • Of these, exercise had the greatest effect on decreasing dementia risk • Following > 4 of above about 60% less likely to get dementia

Physical Activity (PA) is associated with

Memory & Thinking

CDC

Clearer thinking Decrease in cognitive decline Less brain shrinkage

PA x 1 yr shows a small increase in the hippocampus (memory)

29 trials with regular aerobic PA showed an improvement in memory, attention, and thinking speed vs nonaerobic PA

Practitioners had enhanced cognition and decreased rate of memory loss

Tai Chi & Dance

Tai chi improves balance and decreases risk of falls

Dancing helps with memory, planning, organization CDC

Osteoporosis Adults > 50 years:

6.5% of men and 29.1% of women have osteoporosis

Kemmler 2020, Zhang 2022

Exercise effects: After exercise OP patients have significant improvement in QOL, pain score, and balance

High intensity exercise improves bone health and function

Osteoporosis Exercise can improve bone mineral density

Mind Body Exercise is the most effective to increase BMD

3-5 session/wk of weight bearing exercise for 45-60 min in post menopausal women can increase BMD in hip and spine

Falls “Moderate certainty that exercise interventions yielded a moderate benefit in fall reduction among older adults at risk” (Grade B recommendation) USPSTF, AMA June 2024

Data from 83 randomized trials: PA significantly associated with reduced risk of >1 falls and injurious falls

Gait training, balance training, functional training, strength/resistance training all associated with decreased falls

Heart Failure Obesity related Heart Failure with preserved Ejection Fraction HFpEF is a unique phenotype of HF

More symptoms

Weight loss is preventive and improves established HF

Risk of HF doubles in obese vs normal BMI

For every 1 unit increase in BMI, incidence of HF increases 5% for men and 7% for women

Heart Failure • Lack of PA is associated with: • Cardiac atrophy • Decreased cardiac output & chamber size • Decreased cardiorespiratory fitness

• PA in younger-middle age can be preventive • HFpEF is a subset of normal hearts that are small from under exercise

Atrial Fibrillation

Not purely an electrical problem

Weight loss of >10% decreased AF recurrence by 6x

Cancer & Physical Activity (PA) 750K people meeting government recommendation of 2.5 hours of moderate activity had lower risk for 7 of 15 cancer types as compared to sedentary cohorts

Highly active people tend to be of higher socioeconomic status, leaner and healthier

Exercise may help inhibit tumor growth or upregulate the immune system

Journal of Clinical Oncology 2019

Cancer

“We believe there's strong evidence to suggest at least 8 different types of cancer are associated with a level of physical activity (PA)”

American Cancer Society 2020

“We definitely can’t say exercise reduces the risk of all cancer”

Exercise Oncology Program at Memorial Sloan Kettering Cancer Center

Cancer Body weight is a big confounder and PA helps prevent weight gain

Still, studies show association between exercise and many cancers remains significant after adjusting for BMI

Most studies have been on aerobic exercise

Not much known about strength training, household chores, and moderate heart rate elevating exercises

Protective effect of exercise strongest for breast and colon cancer, but that might be because they are common and its easier to detect an association Dana Farber Breast Oncology Center

Cancer

Exercisers had a higher risk of prostate cancer 12% and melanoma 20% Cancer Cell Feb 2024

There is a lack of connection between PA and colon, gastric, bladder, endometrial, and renal cancer

Over many studies, people with the highest PA had a 10-20% decreased risk of cancer. This is probably an underestimate

Cancer One study’s highest PA level may be another's midrange

2019 Physical Activity Advisory Committee

Cancer Cancer risk for PA group

Cancer Cell Feb 2024

Body Part

Risk Reduction

Head/Neck

26%

Lung

20%

Breast

11%

Cancer Cancer risk for PA group Body Part

2.5 hours PA

5 hours PA

Breast

6%

10%

Colon

8%

14%

Endometrial

10%

18%

NHL Women

11%

18%

Liver

18%

27%

Journal of Clinical Oncology 2019

Conclusions • Physical Activity of all types can potentially prevent disease / limit burden of disease • Women are more prone to develop disease from excess weight • Women benefit more from exercise vs men • The rise of sedentary lifestyles will have a tremendous impact on healthcare • PA has been poorly and under investigated as a treatment option for a variety of diseases • Current data is often contradictory, nonspecific, and limited

• A special thanks to Neil Shewell for help with the graphics!

THANK YOU!