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Aerobic Exercise for Disease Prevention and Treatment

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aerobic exercise for disease prevention and treatment

Introduction:

Patients should seek approval by primary physician prior to starting an exercise program. Aerobic exercise generally consists of mild to moderate intensity activity with rhythmic contraction of major muscle groups over an extended period of time. Examples include fast walking, jogging, cycling, Zumba, cross country skiing, and swimming. For the  physician or fitness professional, the following source is the most credible reference for initiation of exercise in patients: Walter R. Thompson, American College of Sports Medicine, Neil F. Gordon, Linda S. Pescatello. ACSM’s Guidelines for Exercise Testing and Prescription. Lippincott Williams & Wilkins, Feb 1, 2009. (1)

 

Benefits of aerobic exercise:

The data provided below illustrates many benefits of aerobic exercise in cardiopulmonary (heart and lung) conditioning, improved pumping efficiency of the heart, improved circulatory system (2), reduce incidence of cancers (3,4), weight control (5), cholesterol reduction (5,6), triglyceride lowering (5), lowering of blood pressure (7), lower rate of smoking (8), improvement of bone mass (13), control of diabetes (15,16), enhanced cognitive performance (17,18,19). Patients also report less depression, improved sleep and better quality of life with aerobic exercise. Aerobic exercise results in reduction of cancer mortality (3), cardiac mortality (8), and all-cause mortality (8). According to the World Health Organization, regular exercise is recommended for not only all healthy individuals, but also those suffering from obesity, diabetes, hypertension, atherosclerotic cardiovascular disease and cancer. (25)

 

Starting exercise in apparently healthy adults:

According to the American College of Sports Medicine (ACSM) and the American Heart Association (AHA): Older adults need moderate-intensity (between 5-6 on a 10-point scale) aerobic endurance activity for a minimum of 30 min which can be achieved in short 10 minute sessions on five days each week or vigorous-intensity aerobic, (rated a 7-8 on a 10-point scale) activity for a minimum of 20 min on 3 days each week.  Adults should also perform muscle-training exercises 2-3 days each week using a variety of exercises (8-10 exercises involving the major muscle groups). For each exercise, 10-15 repetitions are recommended to improve strength. Additionally, older adults at risk of falling should do flexibility exercises at least 2 or 3 days each week to maintain or improve balance. (6)

 

According to the World Health Organization:

The most benefit from physical activity is achieved with at least 2.5 hours of aerobic exercise of moderate intensity per week, which can be accumulated in 10-minute periods. At least 2 days/week vigorous intensity aerobic exercise and resistance exercises for muscle strengthening are recommended. Increased intensity, frequency and duration of exercise is associated with increased added health benefits. (25)

 

American College of Sports Medicine (ACSM) Cardiorespiratory Training Guidelines:

Main components of an exercise session per ACSM include warm-up, conditioning stimulus, and cool down. Warm-up before the session and cool down after the session of exercise consists of 5-15 minutes of activity at 50% training intensity of the conditioning stimulus. One should be easily able to hold conversation at 50% intensity.

 

Aerobic exercise intensity:

Aerobic exercise intensity may be done continuously or intermittently during the day 3-5 days per week initially for 30 minutes per day at moderate intensity to start and increase duration and intensity as tolerated.

Determining Intensity according to the ACSM:

Estimate the maximum heart rate (MHR) in beats per minute by calculating 220 – age. Determine resting heart rate while counting pulse in beats per minute by feeling the radial artery of the wrist after lying down comfortable for more than 10 minutes. Take MHR and subtract resting heart rate (RHR) to calculate heart rate reserve (HRR). MHR – RHR = HRR. Calculate training intensity (TI) by multiplying HRR by desired training intensity generally between 40% and 85% and add back the RHR. TI = HRR x TI + RHR. For beginners start at 40% to 50% for intensity. Once advanced enough by progressive training, the optimum cardiovascular training zone per the ACSM is seen at 75% to 85% training intensity.

 

Training progression according to the ACSM consists of the 3 stages below.

 

Power walking:

This exercise is generally an effective initial aerobic activity for beginners. Start walking at a normal pace and continue to increase the walking speed over 10 minutes to reach a heart rate of 110 – 120 beats per minute resulting in mild perspiration. Then follow the guidelines as described above.

 

Walking to Help Weight Loss Efforts

One of the most commonly recommended exercises for individuals who are overweight is walking because it is not only gentle, but also is a nonthreatening way of including exercise into a lifestyle that thus far has not had any. Some people find the thought of exercising totally debilitating. They watch others sweating profusely while pumping iron, running were doing aerobics and it is enough to make them turn and walk away. But, one of the greatest, simplest and most convenient type of exercise doesn’t require sweating, extra equipment or even the gym. Walking is a means of weight loss exercise will meet the goals of any weight loss program, while gently easing you into a routine that will improve your overall fitness and trim your waistline.

Walking is something that in easy to do each and every day. But, learning to walk as an exercise routine and to improve fitness is different than the standard walk around the block. For example, a walking weight loss routine should be a sustained activity over 30 minutes. Walking outside or Mall walking are both options but the latter is just as effective and sometimes more social. Sustained walking, with arms swinging and blood moving faster than the sound of sludge, can sometimes place more stress on joints and muscles if you change your regular gait.

Supportive shoes to protect the feet, knees and hips is an important addition to a walking program. Old sneakers in the back of the closet may lead to injury. Use well padded socks to prevent blisters and sores. Wear loose fitting clothing to avoid restriction of arms and legs. Walking may bring to mind creative and inventive solutions to problems as the blood flow increases under quiet and calm conditions. Walk with friends or a support partner or use music to enhance motivation. Walking with music helps to pass the time more quickly, takes the mind off the task at hand and helps to keep a good pace. Use a good pair of headphones that remain comfortable for least 30 minutes.

Pace should be increased comfortably yet a person should work to become slightly out of breath so metabolism continues to increase. Do not reach the point where  rapid breathing makes conversation too difficult.

 

Use of fat compared to use of carbohydrates for energy:

An intensity under 25% of maximum oxygen consumption will result is much less aerobic conditioning benefit but still utilize fat oxidation as the body\’s main source of energy. Aerobic exercise intensity of 25% to 65% of oxygen consumption will increase the amount of aerobic oxidative energy production by both carbohydrates and fat. However, fat burning potential is greatest in moderate intensity aerobic exercise done at a rate of 65% of the maximum oxygen consumption. This intensity maximizes aerobic oxidative energy production for the body (9).

 

Starting exercise in chronically ill patients:

Exercise cardiac stress testing referral:

Stress testing should be conducted in patients with suspected or known coronary artery disease, typical and atypical angina or have had prior heart attack. In healthy people, without symptoms, those with multiple heart risk factors (high cholesterol, high blood pressure, family history, obese, diabetes mellitus) or concurrent chronic diseases or those in a high-risk occupation for example pilots, firefighters, law enforcement officers, and transit operators should undergo exercise stress testing. Stress testing is also recommend for men over age 40 and women over age 50 who have been inactive but plan to start vigorous exercise. Evaluation of exercise capacity in patients with heart disease involving one or more of the valves of the heart, those with heart rhythm disorders, and those with pacemakers is also necessary. (27)

 

Clinical cardiopulmonary exercise testing:

Cardiopulmonary exercise testing is done using a treadmill or cycle ergometer. A basic 6 minute walk test may be used to determine baseline exercise capacity before and after medications, surgery, and pulmonary or cardiac rehab programs. Any of these tests may be used as a basic evaluation of exercise capacity, safety and guidelines in patients with coronary heart disease, shortness of breath with/without exertion, lung/heart transplantation, poor exercise tolerance, lung resection, pulmonary hypertension, chronic bronchitis, asthma, interstitial lung disease, heart failure, COPD, cystic fibrosis, peripheral vascular disease, fibromyalgia, advanced age, patients with pulmonary vascular disorders, and for predicting mortality in cardiac patients.

 

Clinical cardiopulmonary exercise testing yields detailed diagnostic information:

Cardiopulmonary exercise testing may provide valuable diagnostic data for a patient\’s poor exercise capacity, assist evaluation of disease conditions, and safely evaluate the patient\’s ability to start and continue an exercise program. Monitors uptake of oxygen, EKG, blood pressure, ventilation, and perceived exertion using a treadmill or cycle ergometer (10). A motivated patient interested in improving their health status despite chronic disease conditions will greatly benefit from a referral for cardiopulmonary exercise testing. Exercise testing will be able to evaluate a patient\’s response to exercise while taking medications. An example includes medications such as beta blockers, including labetalol, which decrease heart rate and blood pressure during rest and exercise. Beta blockers will also increase baseline exercise capacity in patients with pre-existing angina and will either decrease exercise capacity or have no affect on those patients without angina. (27) The 6 minute walk test is a simple test using an area for the patient to walk such as a hallway to determine the distance traveled in 6 minutes. The patient is instructed to walk as far as possible at their desired intensity without jogging. The items required include a timer, cones to mark turnarounds, lap counter, and safety equipment such as defibrillator, crash cart, emergency personnel, oxygen, and chair in the walking area. However, thousands of subjects in several studies have previously performed the test without adverse events. It is contraindicated in those with myocardial infarction or unstable angina within the past month, heart rate over 120 and blood pressure of 180/100. (10,11)

 

Incorporating balance exercise in aerobic activity:

This may help prevent older adults reduce the risk of falls. Among older adults living in the community, a moderate to high-intesity balance exercise program is the most effective in preventing falls. Among older adults living in institutional settings, exercise along with multifactorial interventions are recommended. At a minimum, older adults need at least 50 hours of exercise to prevent falls. (26)

 

Exercise and Asthma According to the National Heart, Lung, and Blood Institute (NHLBI):

Exercise induced asthma or bronchospasm (EIB):

In adults and children with asthma, taking inhaled short and long acting beta2-agonists (such as albuterol, salmeterol, formoterol) before vigorous activity or exercise may prevent EIB, exercise induced asthma, in about 80% of patients. The benefits of treatment may last for 2-3 hours for short  action beta agonist or up to 12 hours if long action beta agonists are used. Additionally, a warm-up period prior to exercise is associated with a lessen degree of EIB. In cold weather, a mask or scarf over the mouth may lessen the effects of cold-induced EIB. Children suffering from EIB should not be excluded from sports and other activities but teachers and coaches should be notified that the child suffers from EIB and may need inhaled medication prior to participation. If symptoms of EIB occur during usual non-vigorous play activities, this may an sign of poorly managed or persistent asthma and long-term treatment may be necessary. Appropriate long-term management may reduce EIB. (28)

 

Additional exercise guidance in patients with serious illnesses:

The most prominent credible source available for exercise prescription is Thompson et al, American College of Sports Medicine\’s (ACSM\’s) Guidelines for Exercise Testing and Prescription. (1) Another valuable source is Gauer, RL and O\’Connor, FG with Department of Family Medicine Uniformed Services University of the Health Sciences, “How To Write An Exercise Prescription.” (27) This can be accessed at: http://www.move.va.gov/download/Resources/CHPPM_How_To_Write_And_Exercise_Prescription.pdf

 

Medication effect upon exercise:

According to Gauer, RL and O\’Connor, FG with Department of Family Medicine Uniformed Services University of the Health Sciences, “How To Write An Exercise Prescription.” Accessed 3/8/2013. (27)

 

Beta Blockers and exercise:

Examples include Lopressor and Toprol XL( metoprolol), Coreg (carvedilol), Tenormin (atenolol), and Bystolic (bisoprolol). Beta blockers reduce heart rate and blood pressure during both rest and exercise. Beta blockers will increase baseline exercise capacity in patients with pre-existing angina and will either decrease or have no affect on those patients without angina.

 

Calcium channel blockers and exercise:

Examples include Adalat and Procardia (nifedipine), Cardizem (dilitiazem), and Calan (verapamil). These drugs will increase baseline exercise capacity in patients with pre-existing angina and have no effect on those patients without angina. During rest and exercise, nifedipine increases heart rate and decreases blood pressure. Dilitiazem and verapamil decrease both heart rate and blood pressure during rest and exercise.

 

Nitrate medications or nitroglycerin and exercise:

These medications increase heart rate and blood pressure during rest and exercise. They will increase baseline exercise capacity in patients with pre-existing angina and have no effect on those patients without angina. In patients with CHF, nitrates will increase or have no affect on baseline exercise capacity.

 

Diuretics and exercise:

These medications increase the production of urine but do not effect exercise capacity except potentially in patients with congestive heart failure by relieving edema in the lungs. Heart rate during rest and exercise is not affected. Blood pressure may decrease or remain unaffected with the use of diuretics. They may lower hydration status.

 

Bronchodilators and exercise:

Methylxanthines such as theophylline, sympathomimetic agents (such as ephedra, pseudoephedrine, amphetamines and methamphetamines), cromolyn sodium, and corticosteroids such as prednisone or methylprednisolone increase exercise capacity in patients with limited bronchospasm. During rest and exercise, methylxanthines and sympathomimetic agents (albuterol) increase or have no effect on heart rate and blood pressure. Sympathomimetic agents may also increase blood pressure during rest and exercise. Cromolyn sodium and corticosteroids have no effect on either heart rate or blood pressure during rest and exercise.

Hyperlipidemic agents and exercise:

These medications with the exception of clofibrate and nicotinic acid (also known as niacin), have no effect on heart rate or blood pressure. In patients with prior heart attack, clofibrate and dextrothyroxine may increase arrhythmias and angina. If you are taking dextrothyroxine, it is advisable to discontinue it because it was pulled from the market due to cardiac adverse effects. During rest and exercise, dextrothyroxine may increase heart rate and blood pressure and worsen myocardial ischemia. Probucol is a cholesterol lowering agent which decreases LDL but it is advisable to discontinue since it may also lower HDL. Blood pressure is decreased by use of nicotinic acid (Niacin) and use of probucol may decrease heart rate (QT interval lengthens). During rest and exercise, nicotine increases blood pressure and either increases or has no effect on heart rate.

 

Antihistamines and exercise:

Benadryl (diphenhydramine), Claritin (loratadine), and  Zyrtec (cetirizine) which are commonly used to treat an allergic reaction have no effect on heart rate and blood pressure during rest and exercise. They also have no effect on exercise capacity. Cold medicine with sympathomimetic agents may increase heart rate or blood pressure during rest and exercise.

 

Levothyroxine (or brand name Synthroid) and exercise:

This thyroid hormone replacement medication increases heart rate and blood pressure during rest and exercise. It has no effect on exercise capacity except if a patient has angina, it may become worse.

 

Alcohol and exercise:

Alcohol has no effect on heart rate but chronic use of alcohol increases blood pressure during rest and exercise. Alcohol has no effect on exercise capacity.

 

Hypoglycemic (blood sugar lowering agents) and exercise:

These medications include insulin and oral agents which have no effect on heart rate and blood pressure during rest and exercise. They also have no effect on exercise capacity.

 

Evidence-based benefits of aerobic exercise:

Exercise and weight loss:

Annual statistics kept by the Centers for Disease Control and Prevention indicate that the number of individuals in the United States who are overweight and obese is increasing at an alarming rate. New theories appear regularly about the reason that people have difficulty managing a healthy weight. These theories include suggestions of genetic abnormalities, a heavy bone structure, defected metabolism or viruses.

But the cold hard truth is that everyone can lose weight when they are in a negative calorie balance. This means that an individual must eat less calories than they burn or, said another way, they burn more calories than they eat. Achieving a negative calorie burn can be accomplished using several different techniques. The most common way to achieve this is to eat less and exercise more. But, before undertaking any fitness program to achieve weight-loss goals, the primary care physician should be consulted to determine the level of exercise intensity and the length of time at which to begin. The primary care physician will make suggestions based on current health, fitness level and any interactions that exercise may have with current medications and any underlying medical conditions.

As the body continues to age, less food will be required in order to maintain body weight or conversely, require less food in order to gain weight. Many individuals find that their basal metabolic rate changes drastically when they hit the age of 30, again at 40 and once again at 60. Basal metabolic rate or BMR is the number of calories required to keep the body alive if one is lying in bed all day. It is the number of calories burned by digestion, muscle and breathing. This number can be estimated using current height, weight, age and gender. There are other factors as well, but these four are the most commonly used in BMR calculators. The older the person, the less calories needed to maintain body weight.

Using a healthy weight loss plan to achieve a negative calorie balance requires both fitness and a healthy diet. Although the need for exercise and fitness has been well publicized to achieve a negative calorie burn and raise their metabolism for long-term weight loss, many people may not be aware of the equally important benefits to health and wellness.

By increasing the heart rate and respiratory rate through exercise, patients are able to increase blood flow through the circulatory system, increase the efficiency of the heart, decrease blood glucose and improve lung function. For diabetics regular exercise will help to maintain blood glucose levels and often times decrease the amount of insulin required.

Achieving fitness increases flexibility and strength which helps patients to perform their daily routine with less discomfort. It increases energy levels, self-esteem and self-awareness of the body. Many report that they feel muscles they’d forgotten they even had. For these benefits to take effect it is important that the routine have both intensity and duration. The intensity of the fitness routine will equal how fast the heart rate goes and for how long.

The duration describes just how long you’re doing the exercise routine. Although both intensity and duration are important factors, if the initial level of fitness doesn’t allow the individual to exercise for more than 10 minutes then incorporating a 10 minute fitness plans three times throughout the day will give similar benefits to doing 30 minutes all at once. Then, as the fitness level improves, you will be able to maintain a greater intensity for a longer length of time.

The goal in any fitness program designed for weight loss is to do a moderate amount of exercise while maintaining that intensity level for 45 minutes to an hour and a half. The amount of time (duration) which is chosen for the exercise program will relate to an individual’s lifestyle, overall health, amount of weight required for loss and the motivation of the individual. The individual should also be working to add a greater intensity level that results in producing sweat for at least half the work out and slightly out of breath when completed.

For those who are moderately to severely overweight only use low-impact aerobic activities to decrease the potential for damage to the joints. These types of activities include swimming, running in the pool, roller blading and walking. They are great exercises that continue to increase the heart rate while not damaging the joints.

Fitness weight-loss programs will improve quality of life, lower risk of heart attack, stroke, peripheral vascular disease, heart disease, vascular disease, inflammatory disease and cancer. It is a gentle way of making changes to lifestyle and should increase success rate for any weight-loss program.

 

Aerobic exercise, weight loss and cholesterol control:

A study done by Barnard, et al. compared 51 to 64 year old subjects from an exercise group that did a consistent exercise program for at least 10 years, a diet plus exercise group who did a consistent diet and exercise program for at least 10 years, and a sedentary group with poor diet. Based on this used as a comparison, if someone began to exercise 5 days per week for one hour in their 50s for 10 years without a change in diet, they should expect to decrease their body mass index about 11.5 kg/m^2, reduce total cholesterol by about 11 points, and reduce their triglycerides by about 105 mg/dl. There was no large benefit in LDL and HDL seen in the group which consumed a poor diet. If someone began to exercise 4-6 days per week for one hour in their 50s for 10 years with eating a low fat, high fiber and complex carbohydrates diet along with exercise they would attain the following average benefit. A decrease in their body mass index about 16.5 kg/m^2, reduce total cholesterol by about 33 points, reduce LDL by about 20 points, and reduce their triglycerides by about 109 mg/dl. There was no large benefit in HDL seen in this study.(5)

 

Aerobic exercise may reduce the risk of cancer and cancer mortality:

Aerobic Exercise and lung cancer:

Alfano et al. completed a study, drawn from the beta-Carotene and Retinol Efficacy Trial, a lung cancer chemoprevention trial, examining physical activity and lung cancer incidence and mortality among 7,045 (59% male) current and former smokers with a mean age of 63 years. Compared to non-active participants, an increase in physical activity resulted in a 14% decreased risk for all-site cancer among men; a 16% decrease risk for lung cancer and a 15% decrease for cancer mortality was seen among younger participants only. Among women, they reported no association between physical activity and lung cancer incidence. Women who were physically active had a 31% decreased risk of lung cancer mortality compared with women who were not physically active. (3)

 

Aerobic exercise and prostate cancer cells:

A low fat, high fiber diet made the blood much less hospitable to prostate cancer cells in vitro. A study authored by Barnard, et al. consisted of using the blood from 3 different groups of 51 to 64 year old males to treat cultured prostate cancer cells in the lab. They compared the blood placed in petri dishes with prostate cancer cells from 3 different groups. The groups included an exercise group that did a consistent exercise program for at least 10 years, a diet plus exercise group who did a consistent diet and exercise program for at least 10 years, and a placebo group. The diet and exercise group were part of a “Pritikin” program and ate low fat, high fiber and complex carbohydrates along with exercise 4-6 days per week. The exercise group exercised for 1 hour per day 5 days per week at a University program in Nevada but did not have any diet program. The placebo subjects were sedentary with poor dietary intake and felt to be at risk of prostate cancer. The blood from the diet plus exercise group caused a significantly greater rate of apoptosis of cancer cells and less growth rate in cancer cells in vitro than the exercise alone or placebo groups.(4) Serum markers of breast cancer in vivo decreased and apoptosis in breast cancer cells increased in vitro after diet and exercise. A study involving 38 overweight or obese postmenopausal women adhered to a low-fat (10-15% kcal from fat), high-fiber (30-40 g per 1,000 kcal/d) diet, and participated in a daily exercise class for 2 weeks.  The diet and exercise was found to reduce several serum markers for breast cancer including estrogen, obesity, insulin and insulin-like growth factor-I (IGF-I), even while subjects remained overweight or obese. The in-vitro analysis used serum drawn from the study group before and after the 2 week intervention and placed it with cancer cells. It was found that the growth in different types of breast cancer cell lines was reduced by 6.6-18.5%. Cell death of several different cell types of breast cancer also increased by 20-30% after the intervention.(22)

 

Aerobic exercise safely increases endurance in heart failure patients:

Researchers from the European Heart Failure Training Group found benefits of physical rehabilitation in 134 patients (mean age 60 years, 94% male) with chronic heart failure (HF). The extent of heart failure among the patients, using the New York Heart Association Functional Classification system, was II (50%) and III (48%). For 6 to 16 weeks, study participants followed one of two exercise regimens: cycle ergometry (20 minutes 4-5 times per week at an intensity of 70%-80% of a predetermined peak heart rate) or cycle ergomertry combined with calisthenics or body weight exercises (5 days/week with stationary running). Cycle ergomertry warm up and cool down lasted for 1-3 min at 25 W. At the end of the study, improvement in resting catecholamines and hormones (such as epinephrine and norepinephrine) and heart rate variability were associated with a 13% increase in oxygen consumption (VO2) and a 17% increase in exercise duration. Compared to the cycle ergometry alone patients, the 54 patients on a combined exercise regimen achieved significantly better VO2 (2.7 vs 1.2 ml.kg.min-1). VO2 was also found to be linked to the duration of the program; after 16 weeks training VO2 was significantly higher than after 6 weeks (2.6 vs 0.3 ml.kg.min-1). No significant side effects were reported. (12)

 

Aerobic exercise reduces mortality:

Aerobic exercise done along with or without a cardiac rehab program reduces mortality in coronary artery disease.

A systematic review and meta-analysis of randomized controlled trials by Taylor et al found that exercise based cardiac rehabilitation reduces all cause and cardiac mortality and improves a number of cardiac risk factors in patients with coronary heart disease according to this meta-analysis of 48 randomized controlled trials (RCTs) (8940 patients, mean age 55 y). Intervention duration ranged from 0.25–30 months and follow up was between 6–72 months. Patients who received exercise-based cardiac rehab had a significant reduction in all cause mortality of 20% and cardiac mortality of 26% than did patients who received usual care. Groups did not differ for rates of non-fatal heart attack (odds ratio [OR]= 0.79), coronary artery bypass grafting (OR=0.87), or percutaneous coronary intervention (OR=0.81). Cardiac rehabilitation was associated with significant reductions in total cholesterol of 0.37 mmol/L and triglyceride concentrations by 0.23 mmol/L; no significant differences were seen in low \’bad\’ or high-density \’good\’ lipoprotein concentrations. Systolic blood pressure was significantly reduced by 3.2 mm Hg. A significant 36% reduction in patient smoking was reported with cardiac rehabilitation. (8) Silberman and colleagues reported the results of an analysis of patients (n=2974) participating in an intensive cardiac rehabilitation program. The authors reported significant improvements in body mass index (BMI), triglycerides, low density lipoprotein cholesterol, total cholesterol, hemoglobin A1c, systolic blood pressure, diastolic blood pressure, depression, hostility, exercise, and functional capacity at 12 weeks and 1 year. (23) Medicare Part B insurance covers the “Dean Ornish Program for Reversing Heart Disease,” under a new benefit category, “Intensive Cardiac Rehabilitation (ICR). The Ornish program, which teaches a plant-based, meatless diet, meditation and regular exercise, is the only program scientifically proven to reverse heart disease currently offered in hospitals, clinics and physicians offices the Medicare and other private insurance companies are covering. People are empowered with a proven program that can quickly reverse their heart disease and other chronic conditions, allowing them to sustainably transform their lives for the better. Additionally, overall adherence to the program has been 85 to 90%, after one year in hospitals and clinics that have offered it. Findings of 3,780 patients at a program in PA found that the average patient lost 13.3 pounds in the first 12 weeks and 15.9 pounds after 1 year. Significant reductions in systolic blood pressure (BP), diastolic BP, total cholesterol, triglycerides, and LDL-cholesterol after 12 weeks were still significant after 1 year. Exercise capacity increased by 18% after 12 weeks and 24% after one year. Reductions in depression and hostility were still significant after 1 year. Hemoglobin A1C in diabetics continued to decrease after one year. Furthermore, 5% of patients reported improvement in severity of angina (chest pain) after 1 year. Eligibility for the program includes one of the following: a) an acute myocardial infarction within the preceding 12 months; b) a coronary artery bypass surgery; c) current stable angina pectoris; d) heart valve repair or replacement; e) percutaneous transluminal coronary angioplasty or coronary stenting; f) a heart or heart-lung transplant; or, g) other cardiac conditions as specified through a national coverage determination. (24)

 

Aerobic exercise increases bone mass in osteoporosis:

According to According to the American College of Sports Medicine and the American Heart Association (AHA), older adults looking to increase bone strength need moderate-intensity aerobic (endurance) activity for a minimum of 30-60 minutes 4 to 7 days per week (can be achieved in short 10 minute sessions). Those who have been inactive should begin with 5-10 minutes of activity each day. For muscle strength training, exercise should include strength training with weights that can be lifted 10 times 2 to 4 days per week. Daily balance and flexibility training exercises are also recommended as part of the overall program. Consult a physician prior to starting any exercise and refer to the above information on starting exercise in healthy vs. chronically ill adults. (6) The link between exercise and calcium supplements on osteoporosis was examined in 104 college-aged women (mean age of 22.3). Sixty-two of the women with low bone mass were included in a 3-month study (though only 60 completed the study). These women were split into 3 groups: an exercise group (n = 21), a group that took calcium supplements (n = 21), and a control group (n = 20). The women\’s distal radius (forearm) T-scores and midshaft tibia (shinbone) scores were taken both before and after the interventions. Results showed that approximately 60.57% of the 104 participants had low bone mass. After the 3 month interventions, the women in the exercise group showed significant improvement in their distal radius SOS T-scores and midshaft tibia scores, compared to the other 2 groups. The calcium-supplement group also showed improvements compared to the control group. The researchers conclude that their findings show that young women who exercised had the highest improvements in their bone mass, when compared with the women in the calcium-supplement and control groups. (13)

 

Aerobic exercise and liver disease:

Aerobic exercise improved the inflammation and histology of the liver in nonalcoholic fatty liver disease (NAFLD). Sixty patients (75% male, mean age 40.0) with NAFLD participated in this study looking at the link between regular aerobic exercise and insulin resistance, aminotransferase level (high levels signal liver damage or disease) and liver histology after 6 months. All patients were advised to exercise regularly for 30 min/d at least 5 d/wk and trained to achieve around 70% of maximal heart rate. In 45 exercise compliant patients insulin resistance decreased from 6.4 to 1.3, body mass index (BMI) from 26.7 kg/m(2) to 25.0 kg/m(2), waist circumference (WC) from 95.7 cm to 90.8 cm and alanine aminotransferase (ALT) from 84.8 U/L to 41.3 U/L (P < 0.01). No significant change in insulin resistance, BMI, WC and ALT were report at 6-month follow-up in the 15 noncompliant participants. Six of 8 patients in compliant group on repeat liver biopsy showed significant change in steatosis (abnormal retention of lipids within a cell) and necrosis/inflammation. Nonalcoholic steatohepatitis scores improved from 5.3 to 3.35. This study showed that regular aerobic exercise by promoting weight loss resulted in improvement in insulin resistance, aminotransferase level and liver histology after 6 mo. (14)

 

Aerobic exercise, diabetes, blood pressure, cholesterol and blood pressure:

Aerobic exercise improved long term blood glucose control, insulin sensitivity, blood pressure, cholesterol, and risk of coronary artery disease in patients with and without Diabetes Mellitus. Individuals with type 2 diabetics can improve multiple health parameters associated with Diabetes Mellitus through regular exercise. A brisk half-an-hour walk every day can significantly reduce (improve) HbA1c (glycated hemoglobin test indicating how well diabetes is being controlled ), blood pressure, blood lipids and coronary heart disease risk. Exercise regimens should be monitored and tailored to the individual to avoid over-exertion. General practitioner should continually encourage their patient to engage in physical activity, with the aim of improving insulin resistance. (15) Low intensity aerobic exercise of longer duration resulted in more sustained improvement in insulin sensitivity than higher intensity for a shorter time period. Patients with type 2 diabetes mellitus (T2DM) were examined to determine whether exercise programs differing in duration and intensity had different effects on insulin sensitivity (oral glucose tolerance test, ISI) following a 12-week exercise program. Inactive T2DM patients (age 51.2 ± 1.3 years) were assigned to 5 sessions/week and 240 kcal/session of either a low-intensity (50% VO(2peak), n = 27) or a high-intensity exercise group (75% VO(2peak), n = 28). Insulin sensitivity (ISI) increased in both groups 16-24 h after the final exercise session. The interesting fact is that only the low-intensity group had elevated ISI 15 days after the end of training despite each group burning about the same amount of calories per session. The low intensity group spent about 56 minutes per session and the high intensity group about 34 minutes per session. These findings suggest that in T2DM patients, improvements in insulin sensitivity may rely more on exercise duration than exercise intensity. (16) According to the American College of Sports Medicine and the American Heart Association (AHA), moderate-intensity aerobic activity, preferably every day of the week, for a minimum of 30 minutes per day is recommended to improve and maintain cholesterol levels in adults. (6)

 

Aerobic exercise improves cognitive function and impairment:

Aerobic exercise improved multitasking, cognitive flexibility, information processing efficiency, and selective attention especially in women. Baker and colleagues report the results of a randomized, controlled clinical trial involving 33 adults with mild cognitive impairment (MCI) in 17 women with an average age of 70. A group of 23 were randomly assigned to an aerobic exercise group and exercised at high intensity levels under the supervision of a trainer for 45 to 60 minutes per day, 4 days per week. The control group of 10 individuals performed supervised stretching exercises according to the same schedule but kept their heart rate low. Fitness testing, body fat analysis, blood tests of metabolic markers and cognitive functions were assessed before, during and after six-months. A total of 29 participants completed the study. Overall, the patients in the high-intensity aerobic exercise group experienced improved cognitive function compared with those in the control group. Specifically, positive effects were seen in multitasking, cognitive flexibility, information processing efficiency and selective attention compared with the stretching control group. These effects were more pronounced in women than in men, despite similar increases in fitness. On average, effect on women was more than twice that for men. The sex differences may be related to the metabolic effects of exercise, as changes to the body\’s use and production of insulin, glucose and the stress hormone cortisol differed in men and women. Results also indicate deterioration in the cognitive function of women in the control group, suggesting aerobic exercise mitigates the progression of cognitive impairment. This study suggests that rigorous aerobic exercise was an effective, non-pharmaceutical approach to combat the effects of cognitive impairment, particularly for women. (17) Aerobic exercise may improve Alzheimer\’s dementia. Seven cohort studies were compared in an analysis in Germany which discussed the benefits of distance walking, aerobic exercise and various other physical activities in Alzheimer\’s disease and cerebrovascular dysfunction. The study stated that vascular regeneration, organ blood flow, induction of antioxidant pathways, and enhanced angiogenesis has been experienced in individuals with exercise training. A large clinical trial was included in the analysis which suggested a significant reduction of Alzheimer\’s dementia accompanied by extensive cardiovascular changes experienced with exercise. According to the study, exercise may benefit Alzheimer\’s disease by up-regulation of antioxidant enzymes and angiogenesis. Furthermore the study concluded that regular exercise is thought to counteract Alzheimer\’s disease by improving endothelial dysfunction (the ability of blood vessels to respond appropriately to the body\’s blood flow needs), upholding neuronal plasticity, and build a vascular reserve. (18)

 

Aerobic exercise resulted in less brain tissue loss:

Previous research has demonstrated that the human brain gradually loses tissue density after the age of thirty in the frontal, parietal, and temporal cortices as a function of the aging process. A study looked at MRIs of people 55 years and older showed that there were marked differences in brain tissue densities based upon age and amount of aerobic fitness.  The study showed that people involved in cardiovascular fitness greatly maintained more brain volumes and cognitive function in these areas of the brain. (19)

 

Aerobic exercise and risk of disability:

Aerobic exercise may reduce the risk of disability and mortality of older adults into their 80s. Nine lifelong cross-country skiers, with a mean age of 81 years and a history of aerobic exercise and participation in endurance events throughout their lives, where examined to determine whole body aerobic capacity and myocellular markers of oxidative metabolism. A cycle test was used to measure aerobic capacity (VO2 max) and a resting vastus lateralis muscle biopsy was used to measure oxidative enzymes associated with muscle health. Six age-matched, healthy, untrained men were used as a comparison. Results indicated that the athletes had a higher absolute [2.6 vs. 1.6 L•min(-1)] and relative [38 vs. 21 ml•kg(-1)•min(-1)] aerobic capacity, heart rate [160 vs. 146 b•min(-1)], and final workload (182 vs. 131 watts). Among athletes, muscle oxidative enzymes were 54% (citrate synthase) and 42% (βHAD) higher. In summary, compared to their counterparts, the lifelong athletes had better cardiovascular and skeletal muscle health that was associated with lower risk for disability and mortality. (20)

 

Aerobic Exercise and Abdominal Aortic Aneurysm Risk:

Kent et al retrospectively analyzed medical and questionnaire data from 3.1 million patients screened with ultrasound for abdominal aortic aneurysm (AAA) from 2003 to 2008. The analysis affirmed well-known risk factors—male, age, family history, cardiovascular disease, and past smoker—but also discovered new markers of higher or lower risk. Excess weight was associated with increased risk, whereas exercise and consumption of nuts, vegetables, and fruits were associated with reduced risk. (2)

 

Aerobic exercise combined with a weight loss program:

Aerobic exercise improved physical function, pain and a walking test in osteoarthritis patients. Researchers gathered data on the effectiveness of exercise and weight loss for 35 patients, aged 25 or older, with hip osteoarthritis (OA) who were overweight or obese. They participated in an 8-month exercise and weight-loss program. Over the course of the study, self-reported physical function, pain, and walking tests were used to measure the success of treatment. The program resulted in a 32.6% improvement in physical function after 8 months, along with significant improvements in pain and on walking tests. Therefore, the results suggest weight loss and exercise may be used as a treatment for hip OA. (29)

 

Assessment and Plan: Aerobic Exercise for Disease Prevention and Treatment

 

 

 

 

 

 

References:

1.Walter R. Thompson, American College of Sports Medicine, Neil F. Gordon, Linda S. Pescatello. ACSM\’s Guidelines for Exercise Testing and Prescription. Lippincott Williams & Wilkins, Feb 1, 2009.

 

2.Kent KC, Zwolak RM, Egorova NN, Riles TS, Manganaro A, Moskowitz AJ, Gelijns AC, Greco G.Analysis of risk factors for abdominal aortic aneurysm in a cohort of more than 3 million individuals. J Vasc Surg. 2010; 52(3): 539-48. http://aje.oxfordjournals.org/content/171/3/312.long

 

3.Alfano CM, Klesges RC, Murray DM, Bowen DJ, McTiernan A, Vander Weg MW, Robinson LA, Cartmel B, Thornquist MD, Barnett M, Goodman GE, Omenn GS. Physical activity in relation to all-site and lung cancer incidence and mortality in current and former smokers. Cancer Epidemiol Biomarkers Prev. 2004;13(12):2233-2241. http://www.ncbi.nlm.nih.gov/pubmed/15598785

 

4.Barnard , James R., Tung H. Ngo, Pak-Shan Leung, William J. Aronson, and Lawrence A. Golding. A Low-Fat Diet and/or Strenuous Exercise Alters the IGF Axis In Vivo and Reduces Prostate Tumor Cell Growth In Vitro. The Prostate 56:201-206 May 2003. http://www.ncbi.nlm.nih.gov/pubmed/12772189

 

5.Barnard , James R., Tung H. Ngo, Pak-Shan Leung, William J. Aronson, and Lawrence A. Golding. A Low-Fat Diet and/or Strenuous Exercise Alters the IGF Axis In Vivo and Reduces Prostate Tumor Cell Growth In Vitro. The Prostate 56:201-206 May 2003. http://www.ncbi.nlm.nih.gov/pubmed/12772189

 

6.Nelson ME, Rejeski WJ, Blair SN, et al. Physical activity and public health in older adults: recommendation from the American College of Sports Medicine and the American Heart Association. Med Sci Sports Exerc. 2007 Aug;39(8):1435-45. http://circ.ahajournals.org/content/116/9/1094.full.pdf

 

7.Rod S. Taylor, Allan Brown, Shah Ebrahim, Judith Jolliffe, Hussein Noorani, Karen Rees, Becky Skidmore, James A. Stone, David R. Thompson, Neil Oldridge. Exercise-Based Rehabilitation for Patients with Coronary Heart Disease: Systematic Review and Meta-analysis of Randomized Controlled Trials. Am J Med. 2004;116:682–692. http://exerciseprescription.wiki.umt.edu/file/view/Taylor+et+al,+2004.pdf

 

8.Taylor RS, Brown A, Ebrahim S, Jolliffe J, Noorani H, Rees K, Skidmore B, Stone JA, Thompson DR, Oldridge N. Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials. Am J Med. 2004 May 15;116(10):682-92. http://exerciseprescription.wiki.uml.edu/file/view/Taylor%20et%20al,%202004.pdf

 

9.Fat vs. carbohydrate metabolism during aerobic exercise. 19 December 2011. Accessed 2.23.2013. http://www.zowerkthetlichaam.nl/1946/fat-vs-carbohydrate-metabolism-during-aerobic-exercise/

 

10.Sumer S Choudhary and Sanjiw Choudhary. Exercise testing in assessment and management of patients in clinical practice-present situation. Lung India. 2008 Jul-Sep; 25(3): 111–117. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2822334/

 

11.Crapo, Robert et al. ATS Statement: Guidelines for the Six-Minute Walk Test, developed by the ATS Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories. March 2002. http://www.thoracic.org/statements/resources/pfet/sixminute.pdf

 

12.European Heart Failure Training Group. Experience from controlled trials of physical training in chronic heart failure: protocol and patient factors in effectiveness in the improvement in exercise tolerance. Eur Heart J. 1998; 19: 466–475. http://eurheartj.oxfordjournals.org/content/19/3/466.abstract?jkey=0c6067a53464576cee209a6020942dad513b2ef3&keytype2=tf_ipsecsha

13.Shenoy S, Dhawan N, Sandhu JS. Effect of Exercise Program and Calcium Supplements on Low Bone Mass among Young Indian Women- A Comparative Study. Asian J Sports Med. 2012 Sep;3(3):193-9. http://www.ncbi.nlm.nih.gov/pubmed/23012639

 

14.Bhat G, Baba CS, Pandey A, Kumari N, Choudhuri G. Life style modification improves insulin resistance and liver histology in patients with non-alcoholic fatty liver disease. World J Hepatol. 2012 Jul 27;4(7):209-17. http://www.ncbi.nlm.nih.gov/pubmed/22855696

 

15.Klare WR. More physical activity in patients with diabetes. Article in German. MMW Fortschr Med. 2007 May 10;149(19):36-9; quiz 40. http://www.ncbi.nlm.nih.gov/pubmed/17668790

 

16.Li J, Zhang W, Guo Q, Liu X, Zhang Q, Dong R, Dou H, Shi J, Wang J, Yu D. Duration of exercise as a key determinant of improvement in insulin sensitivity in type 2 diabetes patients. Tohoku J Exp Med. 2012;227(4):289-96. http://www.ncbi.nlm.nih.gov/pubmed/22850594

 

17.Baker LD, Frank LL, Foster-Schubert K, Green PS, Wilkinson CW, McTiernan A, Plymate SR, Fishel MA, Watson GS, Cholerton BA, Duncan GE, Mehta PD, Craft S. Effects of aerobic exercise on mild cognitive impairment: a controlled trial. Arch Neurol. 2010 Jan;67(1):71-9. http://archneur.jamanetwork.com/article.aspx?articleid=799013#AuthorInformation

 

18.“Alzheimer\’s disease, cerebrovascular dysfunction and the benefits of exercise: from vessels to neurons.” Klinik Fur Psychiatrie und Psychotherapie, Abteilung Gerontopsychiatrie, Bergische Landstr. 2, Dusseldorf 40629, Germany.  Exp Gerontol. 2008 Jun;43(6):499-504. Epub 2008 Apr 6.  http://www.ncbi.nlm.nih.gov/pubmed/18474414

 

19.“Aerobic fitness reduces brain tissue loss in aging humans.”  Beckman Institute, University of Illinois, Urbana 61801, USA.  J Gerontol A Biol Sci Med Sci. 2003 Feb;58(2): 176-80. http://www.ncbi.nlm.nih.gov/pubmed/12586857

 

20.Trappe S, Hayes E, Galpin AJ, Kaminsky LA, Jemiolo B, Fink WJ, Trappe TA, Jansson A, Gustafsson T, Tesch PA. New Records In Aerobic Power Among Octogenarian Lifelong Endurance Athletes. J Appl Physiol. 2012 Oct 11. http://www.ncbi.nlm.nih.gov/pubmed/23065759

 

21.Walter R. Thompson, American College of Sports Medicine, Neil F. Gordon, Linda S. Pescatello. ACSM\’s Guidelines for Exercise Testing and Prescription. Lippincott Williams & Wilkins, Feb 1, 2009.

 

22.Barnard R, Gonzalez J, Liva M, et al. Effects of a low-fat, high-fiber diet and exercise program on breast cancer risk factors in vivo and tumor cell growth and apoptosis in vitro. Nutr Cancer. 2006;55(1):28-34. http://www.ncbi.nlm.nih.gov/pubmed/16965238

 

23.Silberman A, Banthia R, Estay IS, Kemp C, Studley J, Hareras D, Ornish D. The effectiveness and efficacy of an intensive cardiac rehabilitation program in 24 sites. Am J Health Promot 2010;24:260–266. http://www.ncbi.nlm.nih.gov/pubmed/20232608

 

24.Preventative Medicine Research Institute (PMRI). Ornish Programs Reimbursed by Medicare. http://www.pmri.org/certified_programs.html

 

25.Mendes R, Sousa N, Barata JL. [Physical activity and public health: recommendations for exercise prescription]. [Article in Portuguese]. Acta Med Port. 2011 Nov-Dec;24(6):1025-30. Epub 2012 Feb 20. http://www.ncbi.nlm.nih.gov/pubmed/22713198

 

26.Shubert TE. Evidence-based exercise prescription for balance and falls prevention: a current review of the literature. J Geriatr Phys Ther. 2011 Jul-Sep;34(3):100-8. http://www.ncbi.nlm.nih.gov/pubmed/22267151

 

27.Gauer RL, O\’Connor FG. Department of Family Medicine Uniformed Services University of the Health Sciences. How To Write And Exercise Prescription. http://www.move.va.gov/download/Resources/CHPPM_How_To_Write_And_Exercise_Prescription.pdf

 

28.National Heart, Lung, and Blood Institute (NHLBI). Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. Bethesda, MD: NHLBI; August 2007. http://www.ncbi.nlm.nih.gov/books/NBK7232/pdf/TOC.pdf

 

29.Paans N, van den Akker-Scheek I, Dilling RG, Bos M, van der Meer K, Bulstra SK, Stevens M. Effect of Exercise and Weight Loss in People Who Have Hip Osteoarthritis and Are Overweight or Obese: A Prospective Cohort Study. Phys Ther. 2013 Feb;93(2):137-46. http://www.ncbi.nlm.nih.gov/pubmed/23023813

 

30.Crovetto M, Uauy R. Recommendations for cancer prevention of World Cancer Research Fund (WCRF): situational analysis for Chile. Rev Med Chil. 2013 May;141(5):626-36. [Article in Spanish] http://www.ncbi.nlm.nih.gov/pubmed/24089278

 

31.Centers for Disease Control and Prevention: Overweight and Obesity. http://www.cdc.gov/obesity/data/adult.html/

 

32.The AMerican Journal of Clinical Nutrition: Factors Influencing Varieation in Basal Metabolic Rate Include Fat-Free Mass, Fat Mass, Age and Circulating Thyroxine but Not Sex, Circulating Leptin or Triiodothyronine. http://www.ajcn.org/content/82/5/941.full

 

33.Family Doctor: Diabetes and Exercise. http://familydoctor.org/familydoctor/en/diseases-conditions/diabetes/treatment/diabetes-and-exercise.html

 

34.American Academy of Orthopedic Surgeons: Exercise Walking
http://orthoinfo.aaos.org/topic.cfm?topic=A00419

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