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Regular Physical Activity: Forgotten Benefits

      Both men and women who engage in regular physical activity experience statistically significant and clinically important reductions in the risk of dying from coronary heart disease, the leading cause of death in the United States.
      • U.S. Department of Health and Human Services
      The Surgeon General's Vision for a Health and Fit Nation 2010.
      Physical activity also reduces the risks of developing diabetes, hypertension, and colon cancer; enhances mental health; improves muscle, bone, and joint health, and helps maintain function and preserve independence in older adults.
      • U.S. Department of Health and Human Services
      The Surgeon General's Vision for a Health and Fit Nation 2010.
      In fact, regular physical activity may ameliorate many of the emerging and increasingly prevalent clinical, public health, and fiscal challenges that accompany the “Graying of America.” For example, today, 24% of the US population is 50 years of age and over, and 17 million are aged between 75 and 85 years, a number estimated to grow to 30 million during the next 30 years.

      US Census Bureau. The older population in the United States: 2010-2050 population estimates and projections. Available at: https://www.census.gov/prod/2010pubs/p25-1138.pdf. Accessed June 18, 2015.

      Department of Health and Human Services, Administration on Aging. A profile of older Americans. Available at: http://www.aoa.gov/Aging_Statistics/Profile/2013/docs/2013_Profile.pdf. Accessed June 18, 2015.

      Brisk walking every day for only about 20 minutes, which can be practiced even among the oldest old, confers a 30%-40% reduced risk of myocardial infarction.
      • Manson J.E.
      • Hu F.B.
      • Rich-Edwards J.W.
      • et al.
      A prospective study of walking as compared with vigorous exercise in the prevention of coronary heart disease in women.
      In the US today, 18% of the gross national product of about $2.64 trillion is spent on health care, which is about double the proportion of other developed countries. Of that total, Medicare accounts for 21%, or $554 billion. Most alarmingly, of that total, 28%, or about $170 billion, is spent on health care during the last 6 months of life.

      The Henry J. Kaiser Family Foundation. Healthcare spending in the United States. Available at: http://kff.org/health-costs/issue-brief/snapshots-health-care-spending-in-the-united-states-selected-oecd-countries. Accessed June 25, 2014.

      In this context, it is important to note that physical inactivity accounts for about 2.4% of US health care expenditures, or approximately $24 billion a year.
      • US Task Force on Community Preventive Services
      Recommendations to increase physical activity in communities.
      In patients who have survived myocardial infarction, most clinicians would agree that rehabilitation is essential to reduce risks of subsequent myocardial infarction or stroke. Cardiac rehabilitation is a supervised program that typically includes an exercise plan. Even though patients are referred to cardiac rehabilitation after a heart attack, following discharge perhaps < 15% actually participate in cardiac rehabilitation.
      • O'Connor G.T.
      • Buring J.E.
      • Yusuf S.
      • et al.
      An overview of randomized trials of rehabilitation with exercise after myocardial infarction.
      Such sobering statistics are even more alarming in the general US population. According to Healthy People 2020,
      • Healthypeople.gov
      Healthy People 2020: Physical Activity.
      about 36% of adults engage in no leisure-time physical activity, despite the fact that walking may be comparable to more vigorous exercise in preventing cardiovascular events.
      • Manson J.E.
      • Hu F.B.
      • Rich-Edwards J.W.
      • et al.
      A prospective study of walking as compared with vigorous exercise in the prevention of coronary heart disease in women.
      It also is true, however, that increasing walking time or combining walking with vigorous exercise appears to be associated with even greater risk reduction.
      • Manson J.E.
      • Hu F.B.
      • Rich-Edwards J.W.
      • et al.
      A prospective study of walking as compared with vigorous exercise in the prevention of coronary heart disease in women.
      Although federal

      Office of Disease Prevention and Health Promotion. 2008 Physical Activity Guidelines for Americans, updated 2015. Washington, DC: U.S. Department of Health and Human Services.

      and other guidelines
      • Eckel R.H.
      • Jakicic J.M.
      • Ard J.D.
      • et al.
      2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
      recommend moderate-intensity exercise for at least 30 minutes daily, over three-fourths of US adults do not adhere to these guidelines. Further, the Physical Activity Guidelines for Americans, issued by the US Department of Health and Human Services, recommend that children and adolescents aged 6-17 years should have 60 minutes (1 hour) or more of physical activity each day. Nonetheless, many do not achieve even this modest goal, and no physical activity guidelines exist for children under age 6 years.
      All these sobering statistics should be viewed in the context that physical inactivity, along with cigarette smoking and obesity, are the leading contributors to premature morbidity and mortality.
      • Hennekens C.H.
      • Andreotti F.
      Leading avoidable cause of premature deaths worldwide: case for obesity.
      Specifically, lack of physical activity accounts for 22% of coronary heart disease, 22% of colon cancer, 18% of osteoporotic fractures, 12% of diabetes and hypertension, and 5% of breast cancer.

      Office of Disease Prevention and Health Promotion. 2008 Physical Activity Guidelines for Americans, updated 2015. Washington, DC: U.S. Department of Health and Human Services.

      • Eckel R.H.
      • Jakicic J.M.
      • Ard J.D.
      • et al.
      2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
      Communities can do much to increase levels of physical activity among people of all ages and thereby address this serious public health problem, but so, too, can individual clinicians. Clinicians should screen and refer obese patients to programs that offer intensive counseling for weight control and physical activity. Such a simple, straightforward, and easily achievable objective may be a necessary first step to lower the rates of obesity and physical inactivity in the US today.
      When physicians prescribe physical activity, practical patient questions arise: “What exercise should I do?” “For how long, how often and how hard do I need to exercise?” The precise advantages and disadvantages of all types, intensities, frequencies, and durations of exercise are defined incompletely. However, most current guidelines recommend that, following appropriate screening, clinicians should advise their patients to engage in moderate-intensity cardiorespiratory exercise training for ≥ 30 min·d−1 on ≥ 5 d·wk−1 for a total of ≥ 150 min·wk−1, vigorous-intensity cardiorespiratory exercise training for ≥ 20 min·d−1 on ≥ 3 d·wk−1 (≥ 75 min·wk−1), or a combination of moderate- and vigorous-intensity exercise to achieve a total energy expenditure of ≥ 500-1000 metabolic equivalent·min·wk−1. On 2-3 d·wk−1, adults also should perform resistance exercises with each major muscle group, and neuromotor exercise involving balance, agility, and coordination. Crucial to maintaining joint range of movement, completing a series of flexibility exercises for each of the major muscle-tendon groups (a total of 60 seconds per exercise) on ≥ 2 d·wk−1 is recommended also.
      • Garber C.E.
      • Blissmer B.
      • Deschenes M.B.
      • et al.
      Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskleletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise.
      Unfortunately, most Americans prefer prescription of pills to proscription of harmful lifestyles such as physical inactivity.
      • Hennekens C.H.
      Increasing burden of cardiovascular disease: current knowledge and future direction for research on risk factors.
      In general, any pharmacologic intervention should be an adjunct, not alternative, to therapeutic lifestyle changes such as increasing levels of physical activity. Drugs of lifesaving benefit include statins, aspirin, angiotensin-converting enzyme inhibitors, or receptor blockers, as well as beta-adrenergic blockers. In fact, the concept of a polypill is currently being tested in a large-scale randomized trial.
      • Lonn E.
      • Bosch J.
      • Teo K.K.
      • Pais P.
      • Xavier D.
      • Yusuf S.
      The polypill in the prevention of cardiovascular diseases: key concepts, current status, challenges, and future directions.
      In the future, even if proven to be beneficial, this strategy should be an adjunct, not alternative, to therapeutic lifestyle changes such as increased physical activity as well as avoidance or treatment of obesity and cigarette smoking. Clinicians, however, should not let the perfect be the enemy of the possible because, based on the current totality of evidence, when compared with most pharmacologic therapies, exercise is more readily available at low cost and relatively free of adverse effects.
      • Fiuza-Luces C.
      • Garatachea N.
      • Berger N.A.
      • Lucia A.
      Exercise is the real polypill.

      References

        • U.S. Department of Health and Human Services
        The Surgeon General's Vision for a Health and Fit Nation 2010.
        U.S. Department of Health and Human Services, Office of the Surgeon General, Rockville, MDJanuary 2010
      1. US Census Bureau. The older population in the United States: 2010-2050 population estimates and projections. Available at: https://www.census.gov/prod/2010pubs/p25-1138.pdf. Accessed June 18, 2015.

      2. Department of Health and Human Services, Administration on Aging. A profile of older Americans. Available at: http://www.aoa.gov/Aging_Statistics/Profile/2013/docs/2013_Profile.pdf. Accessed June 18, 2015.

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        • Rich-Edwards J.W.
        • et al.
        A prospective study of walking as compared with vigorous exercise in the prevention of coronary heart disease in women.
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      3. The Henry J. Kaiser Family Foundation. Healthcare spending in the United States. Available at: http://kff.org/health-costs/issue-brief/snapshots-health-care-spending-in-the-united-states-selected-oecd-countries. Accessed June 25, 2014.

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        • et al.
        An overview of randomized trials of rehabilitation with exercise after myocardial infarction.
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        • Healthypeople.gov
        Healthy People 2020: Physical Activity.
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        • Jakicic J.M.
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