John Saxton Professor of Clinical Exercise Physiology
University of East Anglia
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The World Health Organisation predicts that chronic conditions
will be the leading cause of disability by 2020 and that, if not
successfully managed, will become the most expensive problem for
health care systems
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Common chronic conditions
CHDStrokeCOPDDepressionCancersDiabetesArthritisAsthma Kidney
disease Osteoporosis
Slide 4
In England, 15.4 million people are currently living with a
chronic conditionIn England, 15.4 million people are currently
living with a chronic condition It is estimated that up to
three-quarters of those over 75 y are suffering from a chronic
condition, and this figure continues to riseIt is estimated that up
to three-quarters of those over 75 y are suffering from a chronic
condition, and this figure continues to rise By 2030, the estimate
is that the incidence of chronic disease in the over 65s will more
than doubleBy 2030, the estimate is that the incidence of chronic
disease in the over 65s will more than double The treatment of
chronic conditions accounts for 70% of total health and social care
costsThe treatment of chronic conditions accounts for 70% of total
health and social care costs
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The ageing population
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By 2034, it is projected that: nearly a quarter (23%) of the UK
population will be aged 65 y (from 16% in 2008)nearly a quarter
(23%) of the UK population will be aged 65 y (from 16% in 2008) 5%
of the UK population will be 85 y5% of the UK population will be 85
y 76.8 80.4 81.6 66.7 68.8 64.3 0 10 20 30 40 50 60 70 80 90
198120012006-8 LE HLE 70.9 75.7 77.4 64.4 67 62.5 0 10 20 30 40 50
60 70 80 90 198120012006-8 LE HLE Women Men Life expectancy (LE)
versus Healthy Life Expectancy (HLE) Office for National Statistics
2011 Age (years)
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The evolution of man and lifestyle behaviours from Homo erectus
to Homo sapiens
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The world of today is not the environment we evolved in Our
lifestyles have been transformed from that of wandering
hunter-gatherers to sedentary consumers of more than we need to
survive Homo sedentarius Homo obesus from Homo erectus to Homo
sapiens
Slide 9
Mean number of hours per working day in occupational
activities, by sex Self-reported sedentary time Health Survey for
England 2008, Volume 1: Physical activity and fitness
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Prevalence of overweight and obesity Health Survey for England
2009, Volume 1: Health and Lifestyles
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How important is the link between physical inactivity and
chronic disease? How important is the link between physical
inactivity and chronic disease?
Slide 12
As early as the ninth century B.C., the ancient Indian system
of medicine (Ayurveda) recommended exercise and massage for the
treatment of rheumatism Greek philosopher Hippocrates (the father
of medicine) acknowledged the virtues of exercise for physical and
mental health in the 4th century B.C.
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Physical inactivity is estimated to be the principal cause of
~30% of the ischaemic heart disease burden, ~27% of the diabetes
burden and ~21-25% of the breast and colon cancer burdens (WHO
2009).Physical inactivity is estimated to be the principal cause of
~30% of the ischaemic heart disease burden, ~27% of the diabetes
burden and ~21-25% of the breast and colon cancer burdens (WHO
2009). Worldwide, approximately 3.2 million deaths (6% of all
deaths) each year are attributable to insufficient physical
activity (WHO 2010).Worldwide, approximately 3.2 million deaths (6%
of all deaths) each year are attributable to insufficient physical
activity (WHO 2010). World Health Organisation statistics
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WHO 2009
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Evidence for the health benefits of exercise
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Ralph S Paffenbarger Jr 1922 - 2007 Jerry N Morris 1910 - 2009
Steven N Blair 1939 - Bus drivers in their 40s were nearly five
times more likely to develop ischaemic heart disease than
age-matched conductors (Morris et al. 1966; Lancet 2; 553- 559).
40% reduced risk of fatal heart attack and a 50% reduction in
non-fatal coronary events among British male civil servants who
participated in vigorous exercise requiring peaks of energy
expenditure (Morris et al. 1980; Lancet 2: 1207-1210). 28% reduced
risk of all-cause mortality among USA college alumni reporting a
weekly exercise energy expenditure of 2000 kcal.week -1
(Paffenbarger et al. 1986; NEJM 314; 605-613). 7.9% decrease in all
cause mortality for every 1 min improvement in treadmill walking
time (roughly equivalent to 1 MET increase in aerobic exercise
capacity) among men attending medical check-ups at the Cooper
Clinic in Dallas USA (Blair et al. 1995; JAMA 273; 1093-1098).
Slide 17
AICR/WCRF Expert Report 2007
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How much exercise is needed for health and fitness?
Slide 19
WHO Global Recommendations on Physical Activity for Health
(2010) 150 minutes of moderate-intensity aerobic physical activity
or 75 minutes of vigorous intensity aerobic physical activity
throughout the week, or an equivalent combination of the two.150
minutes of moderate-intensity aerobic physical activity or 75
minutes of vigorous intensity aerobic physical activity throughout
the week, or an equivalent combination of the two. For additional
health benefits, aim to increase this to 300 minutes of moderate
aerobic physical activity or 150 minutes of vigorous- intensity
aerobic physical activity per week or an equivalent combination of
the two.For additional health benefits, aim to increase this to 300
minutes of moderate aerobic physical activity or 150 minutes of
vigorous- intensity aerobic physical activity per week or an
equivalent combination of the two. Aerobic activity should be
performed in bouts of at least 10 minutes duration.Aerobic activity
should be performed in bouts of at least 10 minutes duration.
Muscle strengthening exercises (involving major muscle groups) on 2
or more days per week.Muscle strengthening exercises (involving
major muscle groups) on 2 or more days per week. Limit the amount
of time spent in sedentary activities
Slide 20
Objective physical activity levels Health Survey for England
2008, Volume 1: Physical activity and fitness
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Waiting to take the escalator
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Whenever I feel like exercise, I lie down until the feeling
passes
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How can we get people to exercise at the right levels and in
the right way to optimise the health benefits?
Slide 24
The role of exercise in ameliorating the impact of chronic
disease, improving quality of life and survival Exercise in the
management of long-term conditions
Slide 25
Health- related Quality of life & Disease-free survival
Morphological (Body composition) Cardio- respiratory Metabolic
Motor Immunological Molecular Muscular Depression Anxiety Stress
Self-esteem Cognitive function Mood states Sense of control
Perceived fatigue Perceived ability to cope Perceived Physical
attractiveness Social integration Enjoyment of life
PhysiologicalPsychosocial
Slide 26
Can exercise training counteract the adverse physiological and
psychological consequences of disease and its treatments? Function;
quality of life; disease-free survival In those with long-term
conditions, what is the role of exercise in disease modification?
How does exercise interact with drug treatments? Can exercise
counteract the side-effects of drug treatments? Why do some
patients respond/adapt differently to exercise training? What are
the contra-indications to exercise in different clinical groups?
Key research questions:
Slide 27
Where exercise has proven benefits to a clinical group how can
it be optimised?
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F-I-T-T PRINCIPLE TYPE FREQUENCY TIME INTENSITY
Slide 29
Vignettes the application of exercise science to the management
of long-term conditions Optimising exercise rehabilitation in terms
of engagement and health benefits in peripheral arterial disease
Impact of exercise on quality of life and disease-free survival
after cancer Exercise and symptoms of clinical fatigue in multiple
sclerosis
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Affected arteries of the lower limb External iliac artery
Femoral artery Popliteal artery Posterior tibial artery Anterior
tibial artery Dorsalis pedis (palpation point) Aortic and iliac
arteries 30% Femoral and popliteal arteries 80-90% Tibial and
peroneal arteries 40-50%
Slide 32
TREATMENT STRATEGIES FOR IC EXERCISE THERAPY PHARMACOLOGICAL
TREATMENTS CV RISK FACTOR MODIFICATION SURGICAL INTERVENTIONS Stop
smoking and keep walking
Slide 33
A significant proportion of patients do not engage in walking
exercise!! Problem!
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Leg cranking exercise Arm cranking exercise Alternative
exercise rehabilitation strategies - rationale A large proportion
(~ 35%) of patients exceed their leg-cycling aerobic exercise
tolerance during arm-cranking exercise Less exercise pain during
arm-cranking, despite similar perceived exertion and higher blood
lactate at maximal exercise tolerance Zwierska et al. (2006);
EJVES
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Arm-cranking exercise trials
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NIRS time to minimum StO 2 was increased after arm-cranking
exercise training PrePost Calf muscle haemoglobin saturation during
walking (NIRS)
Slide 38
Chi square analysis showed that the proportion of patients in
the arm-cranking group with a favourable hs- CRP profile (defined
as < 1.72 mg.l-1) was higher than in the control group at the
24-week time-point (50% vs 23%, respectively; P < 0.05).
Evidence of a reduction in systemic inflammation after arm-crank
training Circulating hs-CRP Saxton et al. (2008); EJVES
Slide 39
Impact on exercise pain tolerance Zwierska I et al. (2005). J
Vasc Surg 42:1122-30.
Slide 40
Central cardiovascular adaptations? Blood rheology (changes in
viscosity)? Exercise pain threshold/tolerance? Improved blood
flow/distribution linked to improved ability of lower limb arteries
to dilate during exercise Mechanisms?
Slide 41
Nordic pole walking (NPW) study To investigate whether the use
of Nordic poles leads to an improvement in common parameters of
walking performance in patients with intermittent claudication To
compare the cardiopulmonary responses and level of leg-pain evoked
by NPW with those evoked by normal walking exercise in this patient
group
Slide 42
Experimental set-up and Methods Methods N = 20 patients with
intermittent claudication recruited from SVI Patients were
familiarised with the NPW technique, allowed ample practice time,
performed dummy run Two treadmill walks: 3.2 km.h -1 @ 4% gradient
in random order Wide belt H-P-Cosmos Saturn Treadmill
Slide 43
During NPW: The level of claudication pain at MWD was less
despite higher oxygen consumption For 9/20 patients (45%), the NPW
test was terminated for reasons other than claudication pain (e.g.
breathlessness/ breathing hard, mouth dry, very tired, exhausted),
versus only 1 in the normal walking condition These results suggest
that NPW could be a useful ergogenic aid for improving the
cardiopulmonary stimulus to exercise rehabilitation in
claudicants
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Slide 45
There are over 200 different types of cancer
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Pre-diagnosis Treatment / surveillance Recovery /
rehabilitation End of life Lifestyle behaviours influencing QoL /
disease-free survival Cancer survivorship Lifestyle behaviours
influencing risk Lifestyle behaviours influencing QoL Cancer
diagnosis Time-line Disease recurrence / Second primary tumour
Lifestyle behaviours influencing treatment outcome / QoL Stages of
the cancer experience Treatment cycle
Slide 48
908070 60 5040302010 0 Holmes et al. (2005) (Overall mortality)
9-14.9 MET-h/week moderate intensity PA Pierce et al. (2007)
(Overall mortality) 25 MET-h/week total recreational PA Holick et
al. (2008) (Overall mortality) 4-10.2 MET-h/week moderate intensity
PA Irwin et al. (2008) (Overall mortality) 150 min per week
moderate intensity PA Meyerhardt et al. (2006a) (Disease recurrence
or death) 18-26.9 MET-h/week total recreational PA Holmes et al.
(2005) (Breast cancer mortality) 9-14.9 MET-h/week moderate
intensity PA Holick et al. (2008) (Breast cancer mortality) 4-10.2
MET-h/week moderate intensity PA Meyerhardt et al. (2006b)
(Colorectal cancer mortality) 18 MET-h/week total recreational PA %
Risk reduction Breast cancer studies Colorectal cancer studies
Slide 49
908070 60 5040302010 0 Kenfield et al. (2011) (Overall
mortality) 90 min/week normal/brisk pace walking Richman et al.
(2011) (Prostate cancer progression) 3 h/week brisk walking
Kenfield et al. (2011) (Prostate cancer mortality) 3 h/week
vigorous activity % Risk reduction Prostate cancer studies
Slide 50
Weight gain is a problem for breast cancer patients The
majority of women gain weight and % body fat between 1-3 years
post-diagnosis (Irwin et al. 2005; JCO 23, 774-782) Mechanisms of
weight gain? Chemotherapy / endocrine therapy Reduction in lean
body mass and resting energy expenditure Reduction in physical
activity due to fatigue Increased food ingestion linked to coping
mechanisms / treatment-related appetite
Slide 51
Being overweight or obese is negatively associated with
postmenopausal breast cancer risk and survival Obesity is
associated with later stage at diagnosis Regardless of weight at
diagnosis, evidence that every 5 kg increase in body weight confers
a 14% increased risk of all cause mortality (Reviewed in Hede et
al. 2008; JNCI 100, 298-299) 24% improvement in relapse-free
survival evoked by diet-induced weight loss within a year of
diagnosis vs controls who gained weight (Chlebowski et al. 2006;
JNCI 98, 1767-1776)
Slide 52
Randomised controlled trial: The effects of a combined Diet and
Exercise intervention on Biomarkers associated with disease
Recurrence After breast cancer treatment: The Sheffield DEBRA
trial.
Slide 53
Patients 90 post-menopausal women with a BMI > 25 kg/m 2 who
completed their breast cancer treatment 3-18 months previously
randomised to lifestyle intervention or usual care control group
Intervention 6 months 3 supervised exercise sessions per week
comprising 30 min of moderate intensity aerobic exercise (treadmill
walking, stepping, cycling) Individualised healthy eating plan with
the aim of inducing a steady weight loss of up to 0.5 kg each
week
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N=47 N=43 Intervention group Control group Changes in aerobic
fitness mlkg -1 min -1 **
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*
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Depression and quality of life Intervention Group Control Group
Pre Post **
