Wisdom: Past and Present

The importance of lifestyle factors and health behaviors to maintaining health has been recognized for centuries. In 1772, British physician Dr. William Heberden cited an example of exercise being beneficial for cardiovascular disease without knowing the nature of the disease: "I knew one who set himself the task of sawing wood for half an hour each day and was nearly cured."¹

We continue to recognize that promoting beneficial health-related behaviors reduces cardiovascular risk.² Given modern society's various challenges that limit the ease of adopting such behaviors, organized efforts infrastructurally and individually are required to reduce cardiovascular risk through such non-pharmacologic means. The American Heart Association, as part of its strategic goals for 2020 and beyond, has identified seven ideal health metrics: not smoking, a normal body mass index (BMI), physical activity, a healthy diet, normal cholesterol, normal blood pressure, and a normal fasting glucose level.³ In the landmark INTERHEART (Effect of Potentially Modifiable Risk Factors Associated With Myocardial Infarction in 52 Countries) study that spanned 52 countries, nine risk factors (smoking, lipids, hypertension, diabetes, obesity, diet, alcohol consumption, physical activity, and psychosocial factors) accounted for >90% of risk for acute myocardial infarction in men and 94% of the risk in women.⁴ Such identified cardiometabolic metrics are highly correlated and typically modifiable. However, although it is particularly challenging to get patients to change lifestyle behaviors, this action may be the most powerful and underutilized prescription. Observational studies suggest that four out of in five myocardial infarctions may be prevented by adopting low-risk, health-related behaviors.⁵

Exercise Matters

Physical activity is one of the key lifestyle risk factors that warrants attention. Lack of regular exercise and excess sedentary behavior are clearly associated with cardiovascular risk and mortality in both men and women.^6-10 Diminished levels of fitness as measured by exercise testing correlated with increased risk of mortality.¹¹ Even modest incremental increases in physical actvity and exercise yields a measurable reduction in mortality.^12,13 The effect of exercise on health outcomes appears to be dose-dependant. Also, increased physical activity favorably impacts a range of cardiometabolic indices, including weight, blood pressure, glycemic parameters, blood lipids, inflammation, and psychoscial factors.¹⁴ In addition to the health benefits, the fiscal benefits are clear. In 2000 in the United States, national costs associated with physical inactvity topped $76 billion; it is estimated that if 10% of adults began a regular walking program, a $5.6 billion cost savings would be realized.¹⁵ In 2010, the spotlight was on health promotion with two first-of-their-kind national initiatives. US Congress established the National Prevention, Health Promotion, and Public Health Council chaired by the Surgeon General and tasked with developing a national prevention strategy. First Lady Michelle Obama took aim at the epidemic of childhood obesity with the Let's Move! campaign. Further, the US Department of Health and Human Services' health promotion and disease prevention initiative, Healthy People 2020, has made the topic of physical activity a public health priority. The goals of Healthy People 2020 include engaging adults in 30 minutes of moderate physical activity on most days of the week, and ensuring that health care professionals assess patients' physical activity and ways to make progress toward meeting physical activity guidelines.¹⁶ Physician encouragement is key in promoting lifestyle changes.^17,18

The Exercise Prescription

Positioning patients for success in starting and increasing their physical actvity and exercise begins with helping them to identify their reasons for wanting to get active. Reinforce and affirm motivations while highlighting the benefits of exercise. It is recommended to provide information and tips for a safe and comfortable exercise session, including the following recommendations:

1. Considerations of the "E's"

Energy: Exercise should be planned for a time in the day when the patient feels rested and has the most energy. Adequate hydration and food will be important to "fuel" them for the physical activity but suggest the person wait at least 1 hour after eating before starting their exercise session. This is particularly important for patients with diabetes and should include some guidance for managing and monitoring blood sugar levels before and after exercise.

Environment: If the patient is planning to exercise outside, it is recommended that they avoid extreme temperatures ( >85° F or <32° F). Patients should dress apropriately for the weather and wear comfortable, supportive (preferably athletic) footwear. An indoor contingency plan for exercise can help with physical activity consistency during inclement weather.

Effort: The adage "no pain, no gain" should be avoided; instead, encourage a pace that allows patients to comfortably carry on a conversation.

2. Components of the Exercise Prescription: Type, Frequency, Intensity, Duration

Type: Aerobic exercise, such as walking (outside or on a treadmil) and biking (upright or recumbant bike with minimal resistance), is recommended for someone just beginning. The exercise session should start with a "warm up" period with slow walking or no/low resistance bicycling and end with a "cool down" segment at similar intensity. A sample walking program is below. At the end of exercise, encourage the patient to stretch the major muscle groups (e.g., hamstrings, calves, and Achilles tendons) used during exercise by holding each stretch for 20-30 seconds; this can minimize injury and fatigue and increase flexibility. In addition to exercise recommendations, the sedentary patient should be given advice to increase overall actvity, including less sitting, using stairs, and parking a distance from their destinations.¹⁹

Frequency: Encouraging daily exercise can help maintain consistency in exercise beginners. Begin with the amount of time the patient feels is manageable (or you feel is safe based on individual cardiovascular history); this could be as short as 5 minutes. Suggesting that a person exercise for a short time multiple times during the day is also an option for consideration (e.g., 5 minutes at a time , three timesdaily). Once the patient is able to exercise continuously for 30 minutes, it is reasonable to adjust the frequency to 5 days weekly.

Table 1: Beginner Exercise Program

Week	Frequency	Warm-up (RPE 6-10)	Exercise Time	Cooldown (RPE 6-10)
1	Daily	5 min easy walk/bike	5 min medium walk/bike RPE 11	5 min easy walk/bike
2	Daily	5 min easy walk/bike	8 min medium walk/bike RPE 11	5 min easy walk/bike
3	Daily	5-7 min easy walk/bike	11 min medium walk/bike RPE 11	5 min easy walk/bike
4	Daily	5-7 min easy walk/bike	15 min medium walk/bike RPE 11-13	5 min easy walk/bike
5	Daily	5-7 min easy walk/bike	20 min medium walk/bike RPE 11-13	5 min easy walk/bike
6	5x per week	10 min easy walk/bike	25 min medium walk/bike RPE 12-14	5 min easy walk/bike
7	5x per week	10 min easy walk/bike	30 min medium walk/bike RPE 12-14	5 min easy walk/bike

Intensity: Employing a subjective measure of exertion as the person begins to get more active and exercise is useful for the novice. The exercise should feel "somewhat light" and the person should be able to maintain a conversation without experiencing breathlessness. One such useful measure to assess intensity is the Borg Scale of Perceived Exertion (RPE).²⁰ The level of effort corresponds to a number that can be used to estimate heart rate when multiplied by 10. The exercise intensity or effort should feel "fairly light" during during warm up and cool down and increase to "somewhat hard" during the more vigorous aspect of the session as the patient's fitness level improves.

If a "target heart rate" is needed to guide intensity, it is reasonable to suggest 20-30 beats per minute above resting heart rate as a range for exercise for sedentary patients beginning to increase activity (provided this heart rate range is safe and acceptable for the individual). As the patient improves his or her fitness, a more vigorous level of intensity based on the results of the individual's exercise tolerance test (ETT) can be determined and individually prescribed but is not the focus of this article.

Duration: It is reasonable for the sedentary individual to begin slowly and maintain the exercise session for a duration that he or she feels is manageable or that his or her health care provider determines to be safe and appropriate. This may be as few as 3-5 minutes at the outset, but it is most important that the person enjoy the activity and feel well. Success begets success and this will (hopefully!) keep him or her motivated to continue and progress. As previously mentioned, multiple short episodes of exercise during the day are a useful approach to increasing exercise time while avoiding fatigue or overexertion for the sedentary individual.The Physical Activity Guidelines for Americans²¹ include the following recommendation: 150 minutes of moderate aerobic exercise per week (30 minutes/day x 5 days) or 75 minutes of vigorous activity weekly. For sedentary patients, this recommendation may seem a bit overwhelming, and providing participants with a more modest initial regimen is recommended.

3. Keeping Active

It is valuable to discuss a number of resources and strategies to keep your patients motivated. Structured secondary prevention programs, such as cardiac rehabilitation programs, provide an excellent resource for you and your patients to get started and stay on track with lifestyle changes, exercise, risk factor education and modification, and social support. Further, participating in a cardiac rehabilitation program after a cardiac event has been shown to reduce mortality.^22,23 The American Association of Cardiovascular and Pulmonary Rehabilitation maintains a directory of programs on their website (www.aacvpr.org). Fitness trackers and fitness apps are additional options to suggest to your patients to keep them engaged in their physical actvity. There's also interactive video games that can add variety to patients' exercise habits. Engaging a companion for exercise will add an element of support and keep the actvity enjoyable. Finally, suggest that as patients meet their physical activity and exercise goals, they reward this accomplshment with something appropriate that they will enjoy. Prescribing exercise and getting your sedentary patients moving is necessary, needed, and effective.

References

1. Medical Transaction of the Royal College of Physicians. Volume 2. London: Royal College of Physicians; 1772.
2. Eckel RH, Jakicic JM, de Jesus JM, 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. J Am Coll Cardiol 2014;63:2960-84.
3. Lloyd-Jones DM, Hong Y, Labarthe D, et al. Defining and setting goals for cardiovascular health promotion and disease reduction: the American Heart Assoxiation's strategic impact goal through 2020 and beyond. Circulation 2010;121:586-613.
4. Yusuf S, Hawken S, Ounpuu S, et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet 2004;364:937-52.
5. Akesson A, Larsson SC, Discacciati A, Wolk A. Low-risk diet and lifestyle habits in the primary prevention of myocardial infarction in men: a population-based prospective cohort study. J Am Coll Cardiol 2014;64:1299-306.
6. Kokkinos P, Myers J. Exercise and physical activity: clinical outcomes and applications. Circulation 2010;122:1637-48.
7. Myers J, Kaykha A, George S, et al. Fitness versus physical activity patterns in predicting mortality in men. Am J Med 2004;117:912-8.
8. Gulati M, Pandey DK, Arnsdorf MF, et al. Exercise capacity and the risk of death in women: the St. James Women Take Heart Project . Circulation 2003;108:1554-9.
9. León-Muñoz LM, Martínez-Gómez D, Balboa-Castillo T, López-García E, Guallar-Castillón P, Rodríguez-Artalejo F. Continued sedentariness, change in sitting time, and mortality in older adults. Med Sci Sports Exerc 2013;45:1501-7.
10. Paffenbarger RS Jr, Hyde RT, Wing AL, Hsieh CC. Physical activity, all-cause mortality, and longevity of college alumni. N Engl J Med 1986;314:605-13.
11. Blair S, Kohl HW 3rd, Paffenbarger RS Jr, Clark DG, Cooper KH, Gibbons LW. Physical fitness and all-cause mortality:a prospective study of healthy men and women. JAMA, 1989;262:2395-401.
12. Wen C, Wai JP, Tsai MK, et al. Minimum amount of physical activity for reduced mortality and extended life expectancy: a prospective cohort. Lancet 2011;378:1244-53.
13. Arem H, Moore SC, Patel A, et al. Leisure time activity and mortality: a detailed pooled analysis of the dose-response relationship. JAMA Intern Med 2015;175:959-67.
14. Kokkinos P. Physical Activity, Health Benefits, and Mortality Risk. ISRN Cardiol 2012;2012:718789.
15. U.S. Department of Health and Human Services. Preventing Chronic Diseases: Investing Wisely in Health. Preventing Obesity and Chronic Diseases Through Good Nutrition and Physical Activity (CDC website). Available at: http://www.cdc.gov/nccdphp/publications/factsheets/prevention/pdf/obesity.pdf. Accessed on 10/1/2015.
16. Office of Disease Prevention and Health Promotion. Physical Activity (HealthPeople.gov website). 2015. Available at: http://www.healthypeople.gov/2020/topics-objectives/topic/physical-activity. Accessed on 10/1/2015.
17. Calfas KJ, Long BJ, Sallis JF, Wooten WJ, Pratt M, Patrick K. A controlled trial of physician counseling to promote the adoption of physical activity. Prev Med 1996;25:225-33.
18. Shanks L, Moore SM, Zeller RA. Predictors of cardiac rehabilitation initiation. Rehabil Nurs 2007;32:152-7.
19. Gennuso K. Sedentary behavior, physical activity, and markers of health in older adults. Med Sci Sports Exerc 2013;45:1493-500.
20. Borg GA. Psychophysical bases of perceived exertion. Med Sci Sports Exerc 1982;14:377-81.
21. Office of Disease Prevention and Health Promotion. Physical Activity Guidelines for Americans (Health.gov website). 2008. Available at: http://health.gov/paguidelines/guidelines/. Accessed on 10/1/2015.
22. Suaya JA, Stason WB, Ades PA, Normand SL, Shepard DS. Cardiac rehabilitation and survival in older coronary patients. J Am Coll Cardiol 2009;54:25-33.
23. Goel K, Lennon RJ, Tilbury RT, Squires RW, Thomas RJ. Impact of cardiac rehabilitation on mortality and cardiovascular events after percutaneous coronary intervention in the community. Circulation 2011;123:2344-52.

Keywords: Achilles Tendon, Alcohol Drinking, Blood Pressure, Body Mass Index, Cholesterol, Diabetes Mellitus, Dyspnea, Exercise Test, Exercise Tolerance, Fasting, Habits, Health Behavior, Health Personnel, Health Priorities, Health Promotion, Heart Rate, Hypertension, Inflammation, Life Style, Lipids, Motivation, Myocardial Infarction, Pediatric Obesity, Physical Exertion, Risk Factors, Secondary Prevention, Sedentary Behavior, Smoking, Surgeons, Walking

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