1. Exercise Prescription for Health (EPH) ERA / EDTA Vienna 2016
Herbert Löllgen
Joh. Gutenberg – University, Mainz
Remscheid

2. Example for introduction:
2015
Example for introduction:
Short - term exercise improves renal function … with moderate baseline chronic kidney disease.
Enhanced fitness should be considered as a non- pharmacological adjunct in the management of diabetic kidney disease

3. No or seldom activity : 59 % Once per week : 41 %
Europe – Barometer Physical Activity in Europe (Europ. Centre f.Dis. Prev.and Control, ECDC)
42 % of Europeans never exercise or play sports
No or seldom activity : 59 %
Once per week : 41 %
At least 1 /week : Sweden: 70 %
Danemark :68%, Finnland: 66%, Netherlands:58%,
Luxembourg: 54%
No regular physical activity or sports:
Bulgaria 78%, Malta 75%, Portugal 64 %,
Romania and Italy (60%)

4. 2012 Per 2 h. additional screen time :
Screen or sitting time is … Ford ES et. al. 2012, Int J Epidem, 11Studies,Meta-Analysis
Total of 5.5 h /day, but with accelerometer 7.7 h / d
Including sleep time, people are immobile for
75 % of day and night
Conclusion: Relative Risk (RR) for cardiovascular diseases
increases by 68 % (1.68) for sitting time, and by
125 % (2.25) for screen time
Per 2 h. additional screen time :
+ 17 % increase of cardiovascular events
2012

5. Situation in the elderly is even more bad
Increasing number of older people
in a relative good general state (developed countries)
However: Reduced physical activity in the aged,
„Anti-Ageing“ drugs (slo vitamins) without effects !!
>> Physical activity is most effective „Anti-Ageing agent
Physical activity reduces functional ageing (improves fitness) (?) (the only interventions that works)
And what about the recommendations for exercise prescription for health by GP ??

6. Operational Definition of Health
> Genetics, Genes, Inheritance
> Environment (e.g.particulate matter,passive smoking),
„social“ environment, sufficient health care provision
> Health conscious behaviour, esp.
healthy lifestyle i.e. active “Lifestyle“
contributes by 50% to health
(for which the patient is responsible)
Exercise prescription for health should motivate for healthier lifestyle

7. Exercise is even better than some drugs
Physical Activity acts like a drug, is an essential part of therapy (Löllgen, DMW 2013:2253 ff.)
Indications: Many, many (all organs)
Dosage: FITT: Frequency, Intensity, Time (duration), Type (of activity))
Dose - response yes, non-linear relationsship
Somatic effects manifold
Psychoactive effects present, many
Side effects musculo-skeletal problems
Contraindications acute illness
Exercise is even better than some drugs
>>> (Naci,Jama,2013 and Nunan BMC, 2013)

8. „Pleiotropic“ Effects of Physical Activity Rowe et al
„Pleiotropic“ Effects of Physical Activity Rowe et al.,Circulation 2014:798

9. Physical Activity vs. Drug Therapie or Cardiac Surgery Better or equally effective
Physical Actvity Drug /Intervention
Heart Disease: % > % (Statine)
Stable CAD %) > % PCI survival) (12M)
Type II Diabetes % Incidence % Incidence (Metformin)
Hip fracture % > % (Risedronat)
Breast cancer % > %, Häufigkeit und Therapie mit Tamoxifen
Breast cancer recidiv - 54% (mort.) % (mort.) Tamoxifen
Depression Physical Activity vs. Sertralin
60.4% Improvement remission
recidive 30% < recidive 52%
Naci et al., Lancet 2012; Fukuta et al.,EJPC, 2016;Cummiskey,2013; Powell,2013)

10. Effects even with moderate physical activity!!
How much Exercise do we need? Risk reduction by regular physical activity Dose – Response Relationship
Männer
Frauen
Effects even with moderate physical activity!!
(Löllgen et al.,2006,2009)

11. Dose - response relationship Most significant: Risk Reduction from Inactivity to Moderate Exercise
Hupin,2013
> 65ys.)
Löllgen,2009
Life expectany
Lee,2010
Moore,2013
(+ 3 – 7 ys.; Moore, et al. 2013,Schnohr, P., 2013 )

12. Mortality: MET 1.8- 3.6 (upper row) and > 3.6 (lower row)
Intensity also means: „Walking“ vs. Running Results in pts. with hypertension (P.T.Williams, Hypertension,2013:485)
Runner (3907) und „Walker“ (6937), Observation about 10.2 ys.
Mortality: MET (upper row) and > 3.6 (lower row)
All cause Mort. Cardio-Vasc. cerebral HF* Arrhythmia
- 29% - 34 % - 55% % %
- 22 % % % %
*HF:Heart failure
In addition, lower mortality in pts. with diabetes mell.
and chron. kidney disease after regular exercise with „Walking“

13. Effetcs of physical activity on blood pressure Pressure changes (systol.) with different forms of Training (Cornelissen, Smart, March 2013, JAHA)

14. Coronary Artery Disease (IA) Arterial hypertension (- 4 -8 mmHg) (I,A)
Evidence based Indications for Regular Physical Activity in Prevention and Therapy (cohort studies, evidence, class and grade)
Coronary Artery Disease (IA)
Arterial hypertension ( mmHg) (I,A)
Chronic obstructive lung disease (IIb)
Heart Failure (increase of EF !) (I,A)
Cancer (Colon, prostatic,mamma) (IA)
Osteoporosis (esp. women) (IA)
Metabolic Syndrom, Diabetes mellitus (I,A)
Chronic kidney disease (I,A)

15. Evidence for some more diseases
Peripheral arterial disease (IA)
(walking more effective than any drug)
Depression (IA)
Bipolar diseases (IIB)
Cognitive function, Dementia (IA)
Neurological diseases (stroke,
Parkinson‘s disease, fibromyalgie etc.) (IA)

16. Exercise prescription: The situation
Strong evidence (positive effects ) for physical activity and prevention of several diseases (Evidence class A1)
(Löllgen et al.,2009,Sofi et al.,Moore et al., Lee et al.,Nocom et al.Samitz et al.,2012)
Strong evidence for rehabilitation (A1) (ESC guideline)
(Cardio-pulmonary diseases,cancer, metabolic diseases etc.)
Strong evidence for positive effects of physical activity as
therapy for many diseases ,adjuvant and causal
(Löllgen, DMW 2013)

17. So we should prescibe: Exercise for Health (EPH)
First attempt and report: The green prescription
Dr.E.Gossner in Augsburg, Bavaria,Germany (1980) no wider acceptance.
EPH in New Zealand (later in Australia, 1990):
>>> Success, with better motivation of patients,
(Swineburn et al.) USA : Blair,1995 recomm., Khan, BJSM,2011)
EPH in Sweden (2003), Berlin (2005), Dr. Wismach
success thanks to excellent marketing
Individual Exercise Prescription in Germany (since 2005, Löllgen,Sportsmed.,Cologne and, Halle, 2006 Munich),
Sports medicine and sports organisation:
EPH now introduced all over in Germany

18. Frequency : 3 oder 5 x /week Intensity: moderate or vigorous
Exercise Prescription follows the FITT - Rule: Dosage : FITT (ACSM – book oder FYSS-book)
Frequency : 3 oder 5 x /week
Intensity: moderate or vigorous
Time: 75 or 150 min. /week
Type od physical activity:
Endurance, Strength
e.g. treadmill, ergometry,
cross trainer
running, cycling,
walking, swimming
Exercise prescription for health
In Europe

19. Exercise in a Pt. With Hemodialysis Source: Medicine for Life : Movement , 5 x in Broadcast (in German) website: WDR 5 :4.4. – Mediathek

20. Prospective Study in Germany:Training during Hemodialysis (Germany , Anding K, Fuhrmann I, BMJ 2015)
Endurance
Strength

21. Fitness, aerobic capacity: Δ 0.56 V02peak
Basis for Physical Activity (Training) in Adults with Chronic Kidney Disease (Cochrane database,2011, Heiwe et al., Smart NA,2013,Pos.Statement Australia, Howden 2012,2013)
45 Studies with 1863 participants, 32 studies with different kinds of raining (endurance, strength, mixed)
Intensity: vigorous, moderate, duration: min/ session.
Bias :49% vigorous,33% moderate,17% low
Regular training improves fitness significantly (V02 > 60%) (Howden et al.(2013),Smart et al. 2013):
Fitness, aerobic capacity: Δ V02peak
Walking capacity : Δ 0.36%, heart rate : Δ6 /min,
RRdiast:Δ 6.08 mmHg, QoL : ++, neurohumoral function improves, inflammtoric markers decrease

22. Tables for many diseases Exercise prescription for Health
For physicians desk
(Zupet P,Löllgen H;

23. Table for CKD (see www.efsma-scientific.eu)

24. %HRR= ((HRmax-HRRest) X % (Intensity) + HRRest)
Heart Rate Reserve (formula) calculation Recommendation of Training Intensity (by Heart Rate)
%HRR= ((HRmax-HRRest) X % (Intensity) + HRRest)
= x 60% =
Karvonen – Formula (1957, Ann Med Exper Biol Fenn)
Training – HR = HFRest + ( %) x (HRmax-HFRest)
Training during
Dialysis

25. Exercise Prescription for Health (EPH)
For all physicians and all specialities:
Every patient at every consultation with every physician should be asked for regular activity (5th vital sign) and should be counseled to be active.

26. Benefits and Motivation for the Doctor
Image and competence gain as a health consultant,
Improves patient‘s committment
Enhancement of exercise reduces the load on your drug budget
Preparticipation and exercise testing will be refunded by insurance companies and at the same time, is a screening examination for latent disease
On the long run, EPH is cost-effective (Sanghavi et al.,JAMA 2015)
Counseling the patient may be time consuming but not more than prescription of drugs with many side effects

28. The Medical Progress through Exercise Prescription for Health
„Hundreds of years of medical progress, and all you can tell me is
being more active
and eat less“
Thanks for your attention

30. Defizit : Entlassungsbriefe from Hospital Lifestyle, Physical Activity
e.g.: Hospital :STEMI (Stent impl.)
z.B. Reha- Clinic (Hypertension, Obesity, CAD)
Proposal by Sports Medicine
Diät :