Statement on exercise: benefits and recommendations for physical activity programs for all Americans. A statement for health professionals by the Committee on Exercise and Cardiac Rehabilitation of the Council on Clinical Cardiology, American Heart Association

Comprehensive evaluation of the older woman

Nearly 50% of American women will be older than 45 years by the year 2015. Because the life expectancy of women is anticipated to extend to an average age of 81 years by 2050, the aging woman will become the predominant patient seeking health care. These statistics reveal the importance for health care providers to become familiar with the health care needs of this segment of the population. Over their life span, women are more likely to experience disease and disability and subsequently require intervention and treatment. This review is an evaluation of the older woman in the primary care setting. In the first section, which is an overall assessment of the older woman, we introduce common geriatric syndromes that should be recognized by health care professionals. We include an approach to the older woman and specific clinical tools that may be useful for comprehensive evaluation in the outpatient setting. In the second section, we discuss sex-specific illnesses as they relate to the older woman. In the third section, we provide insights on end-of-life issues, cultural competence, and socioeconomic concerns. In the last section, we summarize the key components in the evaluation and management of the older woman. The goal of this article is to provide the health care provider with a clear understanding of factors that must be considered to provide optimal care to these patients.

Long-term effects of exercise training on physical activity level and quality of life in elderly coronary patients--a three- to six-year follow-up

BACKGROUND AND PURPOSE

Physical activity and exercise as part of cardiac rehabilitation after an acute coronary event improves exercise capacity and quality of life in most patients. The aim of the present study was to evaluate physical activity level, health-related quality of life (HRQL) and perceived health three to six years after an acute myocardial infarction or an episode of unstable angina pectoris in elderly patients and compare this to earlier follow-up examination data.

METHOD

STUDY DESIGN

three to six years (mean 4.4 years) after randomization a questionnaire about physical activity level, HRQL and perceived health was mailed to all subjects alive (n = 93) (response rate 96%). The original study population consisted of 101 patients aged > or = 65 years admitted to the Coronary Care Unit at the Karolinska Hospital because of an acute coronary event between 1994 and 1997. The patients were randomized to either a three-month period of aerobic group training three times a week (n = 50; acute myocardial infarction 29, unstable angina pectoris 21) or served as control subjects (n = 51; acute myocardial infarction 31, unstable angina pectoris 20).

RESULTS

Since the one-year follow-up examination eight subjects had died: five in the intervention group and three in the control group. At randomization, the level of physical activity level was similar in the two groups. Those in the intervention group improved their level of physical activity significantly over time (p = 0.05) in contrast to the control group. Measurements of HRQL showed no statistical difference between the groups by use of the EuroQol instrument. However, a small advantage for the intervention group measured over time was noted.

CONCLUSION

It is important to include elderly patients in cardiac rehabilitation programmes after an acute coronary event, since even a short period of supervised exercise training has the potential to positively influence physical activity level for as long as three to six years.

Aerobic exercise and the post myocardial infarction patient: a review of the literature

Meta analyses of randomized controlled tests of cardiac rehabilitation after myocardial infarction demonstrate that regular exercise reduces the risk of overall mortality and cardiovascular mortality. In patients with established coronary artery disease, exercise is associated with improved activity tolerance, modification of risk factors, and improvement in quality of life. Randomized controlled tests demonstrate that whereas older patients after coronary events are substantially less fit than younger patients, they obtain a similar relative improvement of aerobic capacity with a graded conditioning program. However, older adults are enrolled in such programs at a lower rate than other age groups. Despite similar clinical profiles to men, women are less likely to participate in exercise rehabilitation. In this article we discuss the principles of program development, guidelines for monitoring of patients, and facilitation of exercise programs in the Australian context.

Coronary smooth muscle adaptation to exercise: does it play a role in cardioprotection?

Substantial evidence exists supporting the role of chronic exercise in reducing the incidence and severity of coronary vascular disease. Physical inactivity is an independent risk factor for coronary heart disease suggesting that the cardioprotective effect of exercise is due, in part, to an intrinsic adaptation within the coronary vasculature. Surprisingly, a paucity of information exists regarding the intrinsic cellular changes within the coronary vasculature associated with exercise training and even less is known regarding the effect of physical activity on long-term phenotypic modulation of coronary smooth muscle (CSM). The purpose of this symposium is to provide a concise update on the current knowledge regarding CSM adaptation to exercise training and the potential for these adaptations to contribute to exercise-induced cardioprotection. The potential role of CSM in exercise-induced cardioprotection will be approached from two perspectives. First, endurance exercise training effects on the regulation of coronary vasomotor tone via changes in CSM calcium regulation will be reviewed, i.e. short-term functional adaptation. Secondly, we will discuss potential long-term consequences of this altered calcium regulation, i.e. exercise-induced phenotypic modulation of CSM. We propose that exercise training alters CSM intracellular calcium regulation to reduce Ca2+-dependent activation of the contractile apparatus and Ca2+-dependent gene transcription and increase activation of sarcolemmal potassium channels. The overall effect is to increase the gain of the vasomotor system and maintain a stable, contractile CSM phenotype.

Explaining the de-prioritization of primary prevention: physicians' perceptions of their role in the delivery of primary care

BACKGROUND

While physicians are key to primary preventive care, their delivery rate is sub-optimal. Assessment of physician beliefs is integral to understanding current behavior and the conceptualization of strategies to increase delivery.

METHODS

A focus group with regional primary care physician (PCP) Opinion Leaders was conducted as a formative step towards regional assessment of attitudes and barriers regarding preventive care delivery in primary care. Following the PRECEDE-PROCEED model, the focus group aim was to identify conceptual themes that characterize PCP beliefs and practices regarding preventive care. Seven male and five female PCPs (family medicine, internal medicine) participated in the audiotaped discussion of their perceptions and behaviors in delivery of primary preventive care. The transcribed audiotape was qualitatively analyzed using grounded theory methodology.

RESULTS

The PCPs' own perceived role in daily practice was a significant barrier to primary preventive care. The prevailing PCP model was the "one-stop-shop" physician who could provide anything from primary to tertiary care, but whose provision was dominated by the delivery of immediate diagnoses and treatments, namely secondary care.

CONCLUSIONS

The secondary-tertiary prevention PCP model sustained the expectation of immediacy of corrective action, cure, and satisfaction sought by patients and physicians alike, and, thereby, de-prioritized primary prevention in practice. Multiple barriers beyond the immediate control of PCP must be surmounted for the full integration of primary prevention in primary care practice. However, independent of other barriers, physician cognitive value of primary prevention in practice, a base mediator of physician behavior, will need to be increased to frame the likelihood of such integration.

The illusion of improved physical fitness and reduced mortality

PURPOSE

To conduct a computer simulation to assess the effects of measurement error on prospective epidemiological studies that attribute mortality outcomes to apparent changes in the independent variable (e.g., physical fitness or activity) at baseline.

METHODS

As an example, we evaluated the design of the Aerobics Center Longitudinal Study (ACLS). This study compared apparent changes in fitness between two baseline visits to mortality during a subsequent 5-yr follow-up period. Unfit men who were reclassified as fit at the second baseline examination (6.6% of sample) and fit men who were reclassified as unfit (2.3%) had follow-up mortality rates that were between those of men who were consistently classified as fit or unfit. This study design was simulated assuming that differences between baseline treadmill test durations were due to measurement error alone. Based on our own data, we estimated that repeat measurements of treadmill test duration have correlation of r = 0.89 in the absence of any real fitness change.

RESULTS

There is excellent agreement between the published ACLS risk reductions and our simulated reductions for both cardiovascular disease (CVD) and total mortality. Compared with the "Unfit-->Unfit" (the referent group), the estimated relative risks from the simulations for men who were reclassified as fit (i.e., "Unfit-->Fit") were 0.57 for total mortality and 0.52 for CVD mortality, and for men who remained classified as fit ("Fit-->Fit"), they were 0.33 for total mortality and 0.20 for CVD mortality.

CONCLUSION

The imprecision of the fitness measurement alone (i.e., measurement error) is sufficient to produce the reported ACLS risk reductions in initially unfit men who get reclassified as fit in a subsequent clinic visit. This statistical artifact will apply to other studies that use this design.

Aggressive blood pressure management

More than one third of all Americans have high or high-normal blood pressure and are at risk for stroke, cardiovascular disease, kidney disease, and heart failure. Many of these are not diagnosed or are inadequately treated. The large number of untreated individuals at risk for the complications of hypertension, or who have not achieved goal pressures on therapy, require a concerted effort by health care professionals to screen and treat this condition. Aggressive identification and treatment of even high-normal hypertension can reduce adverse outcomes. The importance of aggressive management is outlined in this article.

Inflammatory markers and exercise: differences related to exercise type

PURPOSE

To examine the relationship between elevated inflammatory markers (CRP, fibrinogen, and white blood cell levels) and various forms of exercise for the adult U.S. population while controlling for factors that might influence the relationship.

METHODS

An analysis of the adults age 17 and over who participated in the National Health and Nutrition Examination Survey (NHANES) III was conducted. The main goal of the analysis was to determine whether exercise type was associated with systemic markers of inflammation. Bivariate statistics using chi-square to evaluate different types of exercise according to the presence of elevated and nonelevated inflammatory markers was initially performed. In addition, multivariate models were constructed using each type of exercise activity as the predictor variable and each inflammatory marker as the dependent variable.

RESULTS

A total of 4072 people were included in the analysis. In bivariate analyses, compared with nonexercisers in a specific exercise type, a significant lower likelihood of elevated inflammatory markers was found among regular participants in jogging, swimming, cycling, aerobic dancing, calisthenics, and weight lifting but not for gardening. After controlling for possible confounding factors including age, race, sex, body mass index, smoking, and health status in logistic regression analysis, only regular participants in jogging and aerobic dancing remained significantly less likely to have elevated cardiovascular markers.

CONCLUSIONS

The results of this study indicate that some forms of physical activity are associated with a lower likelihood of elevation of inflammatory markers, although we cannot exclude the possibility that differences may be due to exercise intensity or duration. Future research should be directed toward further exploration of the effects of different types of exercise activity on inflammatory markers and the role of exercise in the prevention of cardiovascular disease.

Are fitness, activity, and fatness associated with health-related quality of life and mood in older persons?

PURPOSE

This study sought to determine whether levels of fitness, habitual physical activity, and fatness are associated health-related quality of life and mood in older persons.

METHODS

The subjects were men (n = 38) and women (n = 44), ages 55 to 75 years, who had milder forms of hypertension, but who were otherwise healthy and not engaged in a regular exercise or diet program. Aerobic fitness was assessed by maximal oxygen uptake during treadmill testing, muscle strength by a one-repetition maximum, habitual activity by questionnaire, fatness by dual-energy x-ray absorptiometry, and body mass index. Health-related quality of life was assessed by the Medical Outcomes Study SF-36, and mood by the Profile of Mood States (POMS). Correlations were determined by bivariate and multivariate regression.

RESULTS

Higher aerobic fitness was associated with more desirable outcomes, as indicated by the POMS anger and total mood disturbance scores and by the SF-36 bodily pain, physical functioning, vitality, and physical component scores. Increased fatness was associated with less desirable outcomes, as indicated by the POMS anger, depression, and total mood disturbance scores and by the SF-36 bodily pain, physical functioning, role-emotional, role-physical, social functioning, vitality, and physical component scores. Higher physical activity was associated with an increased POMS score for vigor and a decreased SF-36 score for bodily pain. Strength was not related to health-related quality of life or mood. Aerobic fitness was the strongest predictor of the SF-36 score for vitality and the POMS score for total mood disturbance, whereas fatness was the strongest predictor of the POMS anger score and the SF-36 bodily pain, physical functioning, and physical component scores.

CONCLUSIONS

Even in the absence of regular exercise and a weight-loss diet, relatively small amounts of routine physical activity within a normal lifestyle, slight increases in fitness, and less body fatness are associated with a better health-related quality of life and mood.

Exercise training without ventricular remodeling in patients with moderate to severe left ventricular dysfunction early after acute myocardial infarction

BACKGROUND

The purpose of this study was to determine whether or not patients with moderate to severe left ventricular (LV) dysfunction benefit from exercise training starting early after acute myocardial infarction (AMI) without deteriorating LV remodeling.

METHODS

We investigated changes in exercise capacity and LV end-diastolic dimension (LVDd by two-dimensional echocardiography) before and after exercise training in 126 patients after AMI. Patients were divided into three groups according to LV ejection fraction (EF) at the beginning of exercise training: 74 patients with LVEF>/=45% (Group H), 35 patients with 35%</=LVEF<45% (Group M), and 17 patients with LVEF<35% (Group L). Exercise training was prescribed at a moderate intensity (50-60% of heart rate reserve or Karvonen's equation). Exercise capacity was assessed by peak work rate (WR) and peak oxygen uptake (VO(2)) by upright cardiopulmonary exercise test before and after 3 months of exercise training. LVDd was measured before and at 27+/-10 months of follow-up period.

RESULTS

At the baseline, Group L had a significantly lower LVEF (H 55+/-7 vs. M 40+/-3 vs. L 30+/-3%, P<0.05), significantly greater LVDd (49+/-6 vs. 52+/-7 vs. 56+/-6 mm, P<0.05), and a higher incidence of anterior infarction (P<0.01) compared with Groups H and M, whereas there were no difference in age, sex, coronary risk factors, the incidence of multivessel disease, prior myocardial infarction, peak WR or peak VO(2) among the three groups. After 3 months of exercise training, exercise capacity increased significantly (all P<0.01) in all groups. The magnitudes of the increases in peak VO(2) (%Deltapeak VO(2): 18+/-20 vs. 15+/-19 vs. 18+/-17%, NS) and peak WR (%Deltapeak WR: 17+/-17 vs. 16+/-14 vs. 15+/-13%, NS) were similar among the three groups. In addition, there was no significant correlation between %Deltapeak VO(2) and baseline LVEF. No increase in LVDd was observed in any group at follow-up (H 48+/-5 to 49+/-4 mm vs. M 53+/-8 to 52+/-8 mm vs. L 57+/-5 to 57+/-7 mm, NS in each group).

CONCLUSION

Patients with moderate to severe LV dysfunction benefit from exercise training starting early after AMI without deteriorating LV remodeling, with a similar magnitude of improvement in exercise capacity to that in patients with mild LV dysfunction.

Leisure-Time Activity among Older U.S. Women in Relation to Hormone-Replacement-Therapy Initiation

Hormone-replacement therapy (HRT) and physical activity are both related to aging and health. U.S. minorities are more likely to be inactive and less likely to initiate HRT than are non-Hispanic White women. The purpose of this investigation was to examine the relationship of race and HRT use with physical inactivity among older women (60+ years). The authors used data from 3,479 women who had participated in the Third National Health and Nutrition Examination Survey (NHANES III), conducted in 1988-1994. NHANES III included an in-person interview and a medical examination. The prevalence of physical inactivity among women who reported ever having used HRT was 28.5% (CI 22.9–34.1%), compared with 40.0% (CI 35.9–44.1%) among those who had never used HRT. Mexican American and non-Hispanic Black women reported higher levels of inactivity than did non-Hispanic White women across HRT-use categories. To promote successful aging, physicians should educate postmenopausal women on the possible health benefits of HRT combined with an active lifestyle.

Comparative study of the strength of the flexor and extensor muscles of the knee through isokinetic evaluation in normal subjects and patients subjected to trans-tibial amputation

This study compares the strength of the flexor and extensor muscles of the knee in a group (A) of 25 patients with unilateral trans-tibial amputation, regardless of cause, and a group (B) of 27 normal volunteers. Measured parameters were peak bending moment, total work, maximum power and flexor/extensor relation. The dynamometer used was a Cybex model 6000, set at velocities of 60 degrees/s and 180 degrees/s (4 and 20 repetitions). Exercise type was concentric, both for flexion and extension of the knee joint. Patients were grouped according to stump size, age and time since amputation. These patients were tested with their prosthesis. Mean age in group A was 35.9 +/- 13 years (age range: 12-59 years). Mean age in group B was 34 +/- 8 years (age range: 19-56 years). Comparison according to subject sex was similar. Data analysis between the amputated and the sound limb reveals strength deficit (bigger deficit at 180 degrees/s), which relates to age but not to stump size. When compared to non-amputated subjects in the measured parameters, negative relations both in the amputated side and the non-amputated side were found. The authors' conclusion is that revision of the parameters used until then for rehabilitation of the patients subjected to trans-tibial amputation is needed.

Correlates of exercise adherence in an African American church community

This study identified correlates of attendance to a community-based exercise program in an African American church congregation. After medical clearance, 48 participants completed measures of social support, health-related quality of life, depression, exercise self-efficacy, and exercise motivation and then participated in an exercise program for 6 months (attendance rate = 27%). Age, a sense of affiliation as a motivator to exercise, and weekly caloric expenditure derived from yard work were positively associated with program attendance, and full- or part-time employment was negatively associated with attendance. The authors concluded that exercise adherence is a complicated phenomenon that is influenced by a variety of environmental, personal, and social factors. Social factors, in particular, may be important in promoting adherence to an exercise program in African Americans.

Genetics and blood pressure response to exercise, and its interactions with adiposity

Regular aerobic exercise has the potential to induce several beneficial health effects, including a decrease in blood pressure level, especially in hypertensive patients and in subjects with high-normal blood pressure. However, it is also well documented that some people show more pronounced blood pressure responses to endurance training than others, despite identical training programs and similar initial blood pressure levels. This kind of variation is an example of normal biologic diversity and most likely originates from interactions with genetic factors. Data from genetic epidemiologic studies indicate that there is a genetic component that affects both resting blood pressure and blood pressure responses to acute exercise. Evidence from molecular genetic studies is scarce, but the first reports suggest that DNA sequence variation in the hypertension candidate genes, such as angiotensinogen, also modify blood pressure responses to endurance training. The current knowledge regarding the role of genetic factors in the modification of blood pressure responses to endurance training will be summarized and discussed.

Prevention of cardiovascular diseases. Coronary artery disease, congestive heart failure, and stroke

Cardiovascular disease leads to significant morbidity and mortality in the older population. Results of risk reduction can be dramatic in terms of patient survival and quality of life. This article reviews evidence for cardiovascular risk factors and disease prevention in older adults. Interventions which reduce morbidity and mortality from coronary artery disease, heart failure, and cerebrovascular disease in the elderly population are examined. Attention is given to the role of cardiovascular disease in older women and in minorities, subsets not well-represented in many studies.

Twenty-five-year trends in physical activity of 30- to 59-year-old populations in eastern Finland

PURPOSE

The purpose of this study was to determine the 25-yr trends in leisure-time physical activity (LTPA), occupational activity (OPA), and commuting activity (CA) in the middle-aged population.

METHODS

Six independent cross-sectional surveys were carried out at 5-yr intervals in the population living in eastern Finland (1972-1997). The common age range of the surveys was 30-59 yr, and the participation rates varied between 70 and 96%. LTPA, OPA, and CA were determined by a self-administered questionnaire. Based on their answers, the people were categorized into high, moderate, and low groups.

RESULTS

The percentage of people who were completely sedentary during their leisure time decreased in both men and women. The estimated average 5-yr decrease was greater in women (-6%) than in men (-3%). Men showed only significant changes in high LTPA (+2.2%), whereas in women both moderate (+4.1%) and high (+1.8%) LTPA increased linearly. The percentage of people with low OPA linearly increased in both men (+3.5%) and women (+3.3%) The proportion of men with high OPA decreased in men (-3.2%) as well as in women (-2.6%). The increase in low CA in men (+5.9%) was twice as great as that in women (+2.6%). Men and women with high OPA increased their LTPA by the greatest extent. In both genders, the increase was almost twice as great as among groups classified as being less active during working hours. The prevalence of people who reported low in all three categories (OPA, LTPA, and CA) remained at the same level (6-8% in men, 7-9% in women).

CONCLUSION

The proportion of the Eastern Finnish populations classified as sedentary or having only moderate physical activity during their leisure time is still very high among both men (75%) and women (82%), even though the percentage of highly active people increased between 1972 and 1997.

Special issues and concerns for the high school- and college-aged athletes

Increasing numbers of high school- and college-aged students are participating in sports. As sport participation and intensity increases, the frequency of associated heat related illnesses and acute and chronic overuse injuries will continue to become more prevalent. The sports medicine physician plays an essential role not only in the practice and treatment of injuries but also in educating athletes about safe and healthy exercise habits that will provide life long benefits.

Nondrug interventions in hypertension prevention and control

This review was undertaken to address the relation of various factors to HBP and their potential for preventing and controlling this widespread problem. With respect to salt intake and BP, the 1999 Workshop on Sodium and Blood Pressure of the (US) National Heart, Lung, and Blood Institute [5] will serve the reader well as a point of departure. The body of the present review provides more detailed discussion especially of recent epidemiologic research, including the DASH-Sodium trial, published more recently than the proceedings of that workshop. The DASH-Sodium trial demonstrates significant increases in SBP and DBP, with sodium intake greater than 65 mmol/d (= 3.7 g NaCl--see equivalencies in Appendix A) and with the usual American diet (versus the DASH diet). These results provide substantial evidence against current dietary practices in many populations where daily intakes of salt are much higher than recommended. We also have addressed alcohol consumption, micronutrients/macronutrients, physical activity and inactivity, obesity, cigarette smoking, and alternative approaches to treatment such as stress reduction/biofeedback, yoga/meditation, and acupuncture. Evidence for the efficacy of certain nonpharmacologic approaches to preventing and controlling HBP is strong. This evidence offers a basis for public health policies and clinical approaches that can greatly affect the incidence and consequences of HBP in the population at large. What is needed now is implementation of the policies and practices addressed here. Unless such action is taken on a large scale, we will have made poor use of the knowledge accrued over decades of research. The clinician is referred to the National Heart, Lung and Blood Institute Web site at www.nhlbi.gov/health/prof/heart/index.htm for resource and guideline information for hypertension. Patients and the general public are referred to the sister web page at www.nhlbi.gov\health\public\heart\index.htm for educational fact sheets and general information on hypertension.

Validity of the simultaneous heart rate-motion sensor technique for measuring energy expenditure

PURPOSE

To determine the validity of the simultaneous heart rate-motion sensor (HR+M) technique for estimating energy expenditure (EE) by comparing it with indirect calorimetry. In addition, we examined the validity of the flex heart rate (FlexHR) method to estimate EE.

METHODS

Ten participants (4 men: 26.7 yr +/- 1.5, and 6 women: 26.5 yr +/-3.3) performed arm and leg work in the laboratory for the purpose of developing individualized HR-oxygen uptake (VO2) regression equations. Participants completed physical tasks in a field setting while HR, VO2, and motion sensor data were collected on a near-continuous basis for 6 h. Accelerometers, one on the arm and one on the leg, were used to discriminate between upper- and lower-body movement. HR was used to predict EE (METs) from the corresponding laboratory regression equation. Predicted values (METs) were compared with measured values (METs) obtained via a portable metabolic measurement system.

RESULTS

The simultaneous HR+M technique showed a significantly stronger relationship with VO2 (R2 = 0.81, SEE = 0.55 METs) in comparison with the FlexHR method (R2 = 0.63, SEE = 0.76 METs) (P < 0.001). The FlexHR method significantly overestimated measured minute-by-minute EE (P < 0.001), whereas the simultaneous HR+M technique did not. The simultaneous HR+M technique accurately reflected time spent in resting/light, moderate, and hard activity, whereas the FlexHR method underpredicted time spent in resting/light activity (P = 0.02) and overpredicted time spent in moderate activity (P = 0.02). The simultaneous HR+M technique also accurately estimated total 6-h EE.

CONCLUSION

The simultaneous HR+M technique is an accurate predictor of EE during free-living activity and provides a valid measure of the time spent in various intensity categories.

Health related quality of life and health status in adult survivors with previously operated complex congenital heart disease

OBJECTIVE

To examine the impact of previously operated complex congenital heart disease on health related quality of life and subjective health status and to determine the relation between these parameters and physical status.

DESIGN

Cross sectional; information on medical follow up was sought retrospectively.

SETTING

Patients were randomly selected from the archives of the paediatric cardiology department, Leiden University Medical Centre, Leiden, The Netherlands, and approached irrespective of current cardiac care or hospital of follow up.

PATIENTS

Seventy eight patients with previously operated complex congenital heart disease (now aged 18-32 years) were compared with the general population.

MAIN OUTCOME MEASURES

Health related quality of life was determined with a specifically developed questionnaire (Netherlands Organisation for Applied Scientific Research Academic Medical Centre (TNO-AZL) adult quality of life (TAAQOL)) and subjective health status was assessed with the 36 item short form health survey (SF-36). Physical status was determined with the objective physical index, Somerville index, and New York Heart Association functional class.

RESULTS

Health related quality of life of the patients was significantly worse than that of the general population in the dimensions gross motor functioning and vitality (p < 0.01). Correlations between health related quality of life and physical status were poor. Patients had significantly worse subjective health status than the general population in the dimensions physical functioning, role functioning physical, vitality, and general health perceptions (p < 0.01). Correlations between subjective health status and physical indices were weak.

CONCLUSION

Adult survivors with previously operated complex congenital heart disease experienced limitations only in the physical dimensions of health related quality of life and subjective health status. Objectively measured medical variables were only weakly related to health related quality of life. These results indicate that, when evaluating health related quality of life, dedicated questionnaires such as the TAAQOL should be used.

Sex hormone-binding globulin levels and cardiovascular risk factors in morbidly obese subjects before and after weight reduction induced by diet or malabsorptive surgery

One of the main goals of weight reduction in morbidly obese subjects is its benefit on coronary heart disease (CHD) risk. A cross-sectional study was designed to randomly assign 79 morbidly obese subjects (27 men and 52 women; age: 30-45 years) either to a diet protocol (20 kcal per kg fat-free mass (FFM); 55% carbohydrates, 30% fat, and 15% proteins) or to malabsorptive surgery (biliopancreatic diversion). Fatness parameters, measured by dual-energy X-ray absorptiometry, lipid profile, insulin, leptin, sex steroid hormones and sex hormone-binding globulin (SHBG) levels were compared at baseline and 1 year after the beginning of the study. The data showed that plasma SHBG levels, but not testosterone levels, correlated negatively to fasting insulin levels and positively to HDL-cholesterol in both men and women. Total leptin levels were significantly lower (P<0.0001) in post-BPD subjects of both sexes compared to dietary treated obese subjects. The logarithm of plasma leptin correlated significantly and positively with insulin but negatively with SHBG.A step-down regression analysis showed that FFM and SHBG, but not insulin levels, were the most powerful independent variables for predicting HDL-cholesterol levels in morbidly obese patients. The negative relationship between SHBG levels and CHD risk appears to be mediated by a concomitant variation in body fatness. Finally, in obese patients, SHBG levels seem to be an indicator of total adiposity rather than an index of an altered insulin/glucose homeostasis.

Screening for traditional risk factors for cardiovascular disease: a review for oral health care providers

BACKGROUND

Cardiovascular disease, or CVD, is associated with a very high rate of morbidity and mortality among people in the United States. Primary and secondary prevention measures will help reduce cardiovascular events and increase the overall health of the patient population.

METHODS

The author conducted MEDLINE and Internet searches and reviewed publications from professional organizations for the most up-to-date information on CVD and associated risk factors.

RESULTS

More than 450,000 articles and monographs on CVD were published in English between January 1990 and May 2001. Of these, approximately 45,000 discussed CVD and risk factors. The author selected and reviewed more than 550 publications on the basis of their relevance to epidemiology, etiology, and primary and secondary prevention of CVD.

CONCLUSIONS

Recent information regarding the pathogenesis and treatment of CVD suggests that oral health care providers can perform screening for risk factors and aid in monitoring of specific conditions that put people at an increased risk of developing and exacerbating existing CVD. Dentists need to take a proactive role in this endeavor.

CLINICAL IMPLICATIONS

As with most medical conditions, oral health care providers play an important function as it relates to the overall health of their patients. This article provides a timely update on CVD and the relationship between CVD and its risk factors, and offers suggestions for oral health care providers as to when they should interact with patients and patients' primary health care providers to possibly reduce the mortality and morbidity of CVD.

Safety and efficacy of resistive training in patients with coronary heart disease

In the past 10 to 15 years, there have been several studies on the acute and chronic responses to resistive training in patients with cardiovascular disease. As a result, the safety and efficacy of resistive exercise has become more evident. Resistive training appears to be safe and effective for promoting fitness and improving risk factors in patients with coronary heart disease. This review addresses the health and fitness benefits in these patients, the established guidelines regarding inclusion and exclusion into programs, guidelines for resistive training exercise prescriptions, and how these guidelines have evolved in recent years. (c) 2000 by CHF, Inc.

GENDER AND RACE PATTERNS IN THE PATHWAYS FROM SPORTS PARTICIPATION TO SELF-ESTEEM

Athletics is the most prominent extracurricular activity in U.S. secondary schools in terms of student participation and school budgets. The latter is often justified on the grounds that healthy bodies produce healthy minds, that school sports boost school spirit, and that participation in school-based sports increases students' self-esteem. In this article we examine the interrelationships among participation in a school-based sport and the benefits assumed to be associated with it. Specifically, we test a model that postulates that school spirit, operationalized as attachment to school, and healthy bodies, operationalized as a sense of physical well-being, mediate the relationship between school sports and self-esteem. Data from the National Longitudinal Study of Adolescent Health on Caucasian and African American girls and boys were employed to test the model. School attachment and physical well-being absorbed the statistical effect of participating in a sport for all four gender-by-race groups. Among Caucasian girls a negative residual effect of sports participation was observed, which suggests that sports participation encapsulates multiple effects with contradictory influences. For African American girls school attachment by itself was not a significant mediator of the effect of sports participation on self-esteem. For all groups a sense of physical well-being was the more powerful mediator.

The optimal dietary strategy to manage risk associated with various dyslipidemias

A successful dietary strategy should reduce coronary heart disease (CHD) endpoints, improve correctable risk factors for CHD, and provide for an overall healthful lifestyle. The therapeutic diet achieves a lowering of low-density lipoprotein cholesterol by limiting saturated fat and dietary cholesterol, avoiding an increase in trans fatty acids, and incorporates the use of dietary adjuncts such as an increase in dietary viscous fiber and dietary plant stanol/sterol esters. For those with elevated triglycerides and low high-density lipoprotein cholesterol, impaired fasting glucose, increased waist circumference and other stigmata of the metabolic syndrome, individualized and supervised weight loss, and regular physical activity is strongly recommended.

Exercise in the healthy older adult

Habitual exercise provides numerous health benefits to the older adult. While dynamic aerobic activities increase stamina and lung capacity, isometric or resistance training improves muscle strength and endurance. Long-term benefits of continued exercise include a decreased risk of death from heart disease, enhanced balance and mobility, a decreased risk of diabetes, and an improvement in depressive symptoms. While the hazards of exercise relate predominantly to extremes of intensity and duration, all older adults should consult with a physician before beginning a new activity program. A prescription for exercise should include both aerobic and resistance training components, and frequent follow-up to improve adherence is highly recommended.

The benefits of exercise in geriatric women

Women 65 years of age and older are the fastest growing segment of the population. As women age, physical inactivity is the leading cause of morbidity and mortality due to coronary heart disease, diabetes mellitus, and hypertension. There is also a loss of both physiologic and psychological capabilities that contributes to an overall reduction in function and independent living. Regular physical activity in geriatric women has been shown to reduce cardiovascular morbidity and all-cause mortality. Further research needs to be done to evaluate the role of regular physical activity in the management of diabetes and hyperlipidemia.

Low compliance with national standards for cardiovascular emergency preparedness at health clubs

There is heightened concern that older adults and individuals with occult or known heart disease are exercising at fitness facilities that do not provide adequate cardiovascular screening and emergency procedures, as outlined in contemporary recommendations. To evaluate adherence to these standards, we surveyed 122 randomly chosen fitness clubs in Ohio (53% response rate; n = 65) that included > 110,000 total members. Special programs for older adults, cardiac patients, or both, were offered at 52% of these clubs. More than one fourth of the clubs (28%) failed to employ pre-entry screening to identify members with signs, symptoms, or history of cardiovascular disease, even though 17% reported one or more cardiovascular emergencies (ie, acute myocardial infarction, sudden cardiac death, or both) in their facility during the past 5 years. Moreover, a majority of the clubs (53%) had no written emergency response plan and 92% failed to conduct emergency response drills as described in published national standards. Only 3% of the centers reported having automated external defibrillators. These findings indicate that staff at public fitness facilities must work to identify members with signs, symptoms, or history of cardiovascular disease and prepare for prompt and appropriate responses to cardiovascular emergencies as described in contemporary national recommendations. Such risk management procedures may reduce exercise-related cardiovascular events among the escalating number of moderate-to-high-risk adults who are being mainstreamed into health and fitness facilities.

Absolute versus relative intensity of physical activity in a dose-response context

PURPOSE

To examine the importance of relative versus absolute intensities of physical activity in the context of population health.

METHODS

A standard computer-search of the literature was supplemented by review of extensive personal files.

RESULTS

Consensus reports (Category D Evidence) have commonly recommended moderate rather than hard physical activity in the context of population health. Much of the available literature provides Category C Evidence. It has often confounded issues of relative intensity with absolute intensity or total weekly dose of exercise. In terms of cardiovascular health, there is some evidence for a threshold intensity of effort, perhaps as high as 6 METs, in addition to a minimum volume of physical activity. Decreases in blood pressure and prevention of stroke seem best achieved by moderate rather than high relative intensities of physical activity. Many aspects of metabolic health depend on the total volume of activity; moderate relative intensities of effort are more effective in mobilizing body fat, but harder relative intensities may help to increase energy expenditures postexercise. Hard relative intensities seem needed to augment bone density, but this may reflect an associated increase in volume of activity. Hard relative intensities of exercise induce a transient immunosuppression. The optimal intensity of effort, relative or absolute, for protection against various types of cancer remains unresolved. Acute effects of exercise on mood state also require further study; long-term benefits seem associated with a moderate rather than a hard relative intensity of effort.

CONCLUSIONS

The importance of relative versus absolute intensity of effort depends on the desired health outcome, and many issues remain to be resolved. Progress will depend on more precise epidemiological methods of assessing energy expenditures and studies that equate total energy expenditures between differing relative intensities. There is a need to focus on gains in quality-adjusted life expectancy.

Physical fitness and activity as separate heart disease risk factors: a meta-analysis

OBJECTIVE

Public health policies for physical activity presume that the greatest health benefits are achieved by increasing physical activity among the least active. This presumption is based largely on studies of cardiorespiratory fitness. To assess whether studies of cardiorespiratory fitness are germane to physical activity guidelines, we compared the dose-response relationships between cardiovascular disease endpoints with leisure-time physical activity and fitness from published studies.

DATA SOURCES

Twenty-three sex-specific cohorts of physical activity or fitness (representing 1,325,004 person-years of follow-up), cited in Tables 4-1 and 4-2 of the Surgeon General's Report.

DATA SYNTHESIS

Relative risks were plotted as a function of the cumulative percentages of the samples when ranked from least fit or active, to most fit or active. To combine study results, a weighted average of the relative risks over the 16 physical activity or seven fitness cohorts was computed at every 5th percentile between 5 and 100%. The analyses show that the risks of coronary heart disease or cardiovascular disease decrease linearly in association with increasing percentiles of physical activity. In contrast, there is a precipitous drop in risk occurring before the 25th percentile of the fitness distribution. As a consequence of this drop, there is a significant difference in the risk reduction associated with being more physically active or physically fit (P < or = 0.04).

CONCLUSIONS

Being unfit warrants consideration as a risk factor, distinctly from inactivity, and worthy of screening and intervention. Formulating physical activity recommendations on the basis of fitness studies may inappropriately demote the status of physical fitness as a risk factor while exaggerating the public health benefits of moderate amounts of physical activity.

Exercise training activates large-conductance calcium-activated K(+) channels and enhances nitric oxide production in rat mesenteric artery and thoracic aorta

Exercise training has reversible beneficial effects on cardiovascular diseases, e.g. hypertension, which may result from a decrease in systemic vascular resistance. The purpose of this study was to investigate possible mechanisms associated with the changes in vascular reactivity in large and small arteries with vasoconstrictors and vasodilators in rats after exercise. Wistar-Kyoto rats were trained for 8 weeks (Ex group) on a treadmill and compared with sedentary counterparts (Sed group). After the measurement of blood pressure and heart rate at 8 weeks, rat mesenteric arteries and thoracic aortas were excised and prepared as rings for this study. In addition, special care was taken not to damage the endothelium of the preparations. Our results showed that exercise training for 8 weeks (1) not only prevented an increase in blood pressure but also caused a fall in heart rate, (2) attenuated the contractions induced by both prostaglandin F(2alpha) (PGF(2alpha)) and high K(+) in the mesenteric artery, but reduced the PGF(2alpha)-induced contraction in the aorta only, (3) enhanced the relaxation elicited by acetylcholine (ACh) in both mesenteric arteries and aortas, and (4) increased nitrate [an indicator of nitric oxide (NO) formation] in plasma. The enhancement of ACh-induced relaxation in the mesenteric arteries in the Ex group was suppressed by pretreatment with N(omega) -nitro-L-arginine methyl ester (L-NAME), tetraethylammonium (TEA; a nonselective inhibitor of K(+) channels) or charybdotoxin [CTX; a selective inhibitor of large-conductance calcium-activated K(+) (BK(Ca)) channels], whereas in the aorta that response was attenuated by TEA or CTX and almost completely abolished by L-NAME. However, with a combination of L-NAME plus CTX in the mesenteric artery, ACh-induced relaxation was completely abolished in the Sed group, but not in the Ex group. These results suggest that in addition to NO, activation of BK(Ca) channels in the vascular beds, at least in part, also contributes to vasodilatation in animals with exercise training.

Improving compliance in your dyslipidemic patient: an evidence-based approach

PURPOSE

To synthesize the evidence from landmark clinical studies of lipid-lowering pharmacotherapy and nurse management of hyperlipidemia, discuss issues related to nonadherence, and proposes strategies for achieving long-term cholesterol control.

DATA SOURCES

All publications of lipid-lowering clinical trials related to pharmacotherapy for dyslipidemias were accessed from a thorough Medline Search and reviewed by two nurse experts.

CONCLUSIONS

Randomized controlled studies provide compelling evidence that reduction of blood cholesterol with pharmacotherapy reduces both first and subsequent coronary events. Nonetheless, inadequate provider and patient adherence to guidelines for lipid lowering remains prevalent. Studies show that nurses provide safe and effective care for patients with abnormal lipids.

IMPLICATIONS

This article assists nurse practitioners in playing an active role in the implementation of the National Cholesterol Education Program Adult Treatment Panel III Report to be released in Spring 2001, where a strong emphasis will be placed on multidisciplinary approaches and adherence.

Skeletal muscle training in chronic heart failure

Patients with heart failure are limited in their ability to tolerate exercise. Recent research has suggested that this limitation cannot be entirely attributed to cardiac or lung impairment but rather that changes in peripheral muscles may play an important role. There are objective similarities between heart failure and muscular deconditioning. Deficiencies in peripheral blood flow and skeletal muscle function, morphology, metabolism and function are present in both conditions. Moreover, an exaggerated activity of the receptors sensitive to exercise-derived metabolic signals (muscle ergoreceptors and peripheral and central chemoreceptors) leads to early and profound exercise-induced fatigue and dyspnoea. These muscle afferents contribute to the ventilatory, haemodynamic and autonomic responses to exercise both in physiological and pathological conditions, including chronic heart failure. Against this background, a skeletal muscle origin of symptoms in heart failure has been proposed. The protective effects of physical training have been described in many recent studies: training improves ventilatory control, skeletal muscle metabolism and autonomic nervous system activity. The exercise training appears to induce its beneficial effects on skeletal muscle both directly (on muscle function, histological and biochemical features) and indirectly (by reducing the activation of the muscle afferents). The metabolic mediators of these muscle afferents may become a potential target in the future therapy of heart failure symptoms.

Using the exercise test to create the exercise prescription

Exercise testing can provide valuable information to aid the primary care physician in developing a safe and effective exercise program for his or her patients. This review presents the most recent recommendations for the components of an exercise program as well as methods to accomplish appropriate prescription writing for the various subsets of individuals from the healthy patient to the patient with chronic disease. In addition, a plea is made for physicians to encourage all patients to engage in at least some kind of regular exercise activity in an attempt to counteract the increasingly sedentary lifestyles found in our culture.

Evidence based prevention of acute injuries during physical exercise in a WHO safe community

OBJECTIVE

To evaluate a community based programme for evidence based prevention of injuries during physical exercise.

DESIGN

Quasi-experimental evaluation using an intervention population and a non-random control population.

PARTICIPANTS

Study municipality (population 41,000) and control municipality (population 26,000) in Sweden.

MAIN OUTCOME MEASURES

Morbidity rate for sports related injuries treated in the health care system; severity classification according to the abbreviated injury scale (AIS).

RESULTS

The total morbidity rate for sports related injuries in the study area decreased by 14% from 21 to 18 injuries per 1,000 population years (odds ratio 0.87; 95% confidence interval (CI) 0.79 to 0.96). No tendency towards a decrease was observed in people over 40. The rate of moderately severe injury (AIS 2) decreased to almost half (odds ratio 0.58; 95% CI 0.50 to 0.68), whereas the rate of minor injuries (AIS 1) increased (odds ratio 1.22; 95% CI 1.06 to 1.40). The risk of severe injuries (AIS 3-6) remained constant. The rate of total sports injury in the control area did not change (odds ratio 0.93; 95% CI 0.81 to 1.07), and the trends in the study and control areas were not statistically significantly different.

CONCLUSION

An evidence based prevention programme based on local safety rules and educational programmes can reduce the burden of injuries related to physical exercise in a community. Future studies need to look at adjusting the programme to benefit all age groups.

Lewis phenotypes, leisure time physical activity, and risk of ischaemic heart disease: an 11 year follow up in the Copenhagen male study

OBJECTIVE

To test the hypothesis that the predictive value for risk of fatal ischaemic heart disease associated with Lewis phenotypes depends on the level of leisure time physical activity.

DESIGN

Prospective study controlling for alcohol, tobacco, serum cotinine, blood pressure, body mass index, serum lipids, work related physical activity, and social class.

SETTING

The Copenhagen male study, Denmark.

SUBJECTS

2826 white men aged 53-75 years without overt cardiovascular disease; 266 (9.4%) had the Le(a-b-) phenotype.

MAIN OUTCOME MEASURE

Incidence of death from ischaemic heart disease during 11 years.

RESULTS

107 men died of ischaemic heart disease. Among men with a low level of leisure time physical activity (</= 4 hours/week moderate or </= 2 hours/week more vigorous activity), being Le(a-b-) was associated with an increased risk of having a fatal ischaemic heart disease event compared with men with other Lewis phenotypes (relative risk (RR) 2.7, 95% confidence interval (CI) 1.4 to 5.2; p < 0.01). Among men with a high level of leisure time physical activity, the RR associated with being Le(a-b-) was 1. 3 (95% CI 0.5 to 3.1; NS). Compared with all other alternatives tested, being Le(a-b-) and having a low level of leisure time physical activity was associated with an RR of 3.2 (95% CI 1.7 to 5. 8; p < 0.001). As a point estimate and adjusted for confounding variables, among men with low leisure time physical activity the attributable risk associated with Le(a-b-) was 12%-that is, assuming that all sedentary men had phenotypes other than Le(a-b-), 12% of all fatal ischaemic heart disease events would not have occurred. The corresponding point estimate among those more active was 2%.

CONCLUSIONS

The excess risk of fatal ischaemic heart disease in middle aged and elderly men with the Le(a-b-) phenotype is strongly modified by leisure time physical activity. Public health and clinical implications may be important in populations with a predominantly sedentary lifestyle and in a high proportion of men with the Le(a-b-) phenotype.

Gender-specific effects of modifiable health risk factors on coronary heart disease and related expenditures. HERO Research Committee. Health Enhancement Research Organization

There is a general lack of health-related research focusing on gender-specific differences within a working population. This research attempts to address that void. Our study relied on the Health Enhancement Research Organization (HERO) database, which consists of claims, enrollment information, and health risk data for 39,999 employees of six large employers. The research objective was to determine the gender-specific association between coronary heart disease (CHD) and (1) the prevalence of modifiable health risks and (2) medical expenditures. To accomplish this, the International Classification of Diseases, 9th Revision-Clinical Modification and Current Procedural Terminology codes were used to identify 2452 employees with CHD within the HERO database. These individuals made up the study group, which included 66% male and 34% female participants. Health risk data were obtained from voluntary participation in a health risk appraisal and biometric evaluation provided by the employers. Health risks evaluated were tobacco use, hypertension, obesity, elevated cholesterol, high blood glucose, sedentary lifestyle, stress, depression, and excessive use of alcohol. Descriptive and multivariate statistical techniques were used to analyze the HERO database. We found that obesity was the most consistent predictor of CHD. It was number one (of 10 health risks) in the male and female group, number two in the male-only group, and number one in the female-only group. High stress was the second most consistent predictor. There was no such consistency relative to medical expenditures. This lack of consistency across the male and female groups relative to the association between health risks and medical expenditures was demonstrated for nearly all other health risks evaluated. This study suggests that within a group of employees with CHD, there are important similarities and differences between men and women with respect to the prevalence of risk factors and the association between health risks and medical expenditures.

Characteristics of inactive primary care patients: baseline data from the activity counseling trial. For the Activity Counseling Trial Research Group

BACKGROUND

Although many primary care patients are inactive, being able to classify even small amounts and intensities of activity and factors associated with these activity levels could be helpful for physicians who are trying to motivate their patients to become more physically active.

METHODS

Sociodemographics, physical activity, fitness, other cardiovascular risk factors, and psychosocial measures were measured at baseline in the 874 patients in the Activity Counseling Trial. Patients were categorized into three groups: (1) no moderate-to-vigorous physical activity (MVPA), (2) some moderate but no vigorous activity, and (3) some vigorous activity. Multiple logistic regression was used to determine factors cross-sectionally associated with activity intensity.

RESULTS

One or more cardiovascular risk factors in addition to physical inactivity were present in 84% of participants. Maximal oxygen uptake averaged 25.2 ml/kg/min; 85% had poor to fair aerobic fitness. Physical activity averaged 32.7 kcal/kg/day, with 13.5 min of MVPA/day; 26% engaged in some vigorous activity, 11% engaged in no MVPA. In unadjusted analyses, gender, age, race, education, income, employment, smoking, alcohol use, and exercise self-efficacy were associated with activity intensity (P = 0.05-0.001). A greater percentage engaged in moderate than in vigorous activity in all subgroups. In multiple logistic regression analyses, odds ratios (95% confidence intervals) for engaging in vigorous activity were 0. 39 (0.28, 0.56) for women, 0.38 (0.19, 0.75) for 65+ compared with 35- to 44-year-olds, and 1.14 (1.06, 1.22) for 10-unit increases in performance self-efficacy score.

CONCLUSIONS

Most primary care patients who are physically inactive have additional cardiovascular risk factors, particularly overweight and obesity. All subgroups pursue moderate-intensity activity more often than vigorous activity. Women, older persons, and those with lower exercise self-efficacy are less likely to engage in vigorous activity.

Quality and correlates of physical activity counseling by health care providers in Israel

BACKGROUND

The quantity and quality of physical activity counseling by the health care provider can have a profound impact on improving the physical activity of the older population. This study presents an estimate of the quality and quantity of physical activity counseling and tests the associations of different variables with physical activity.

METHODS

A random telephone survey of 793 Israeli residents between the ages of 45 and 75 was conducted. Counseling by a health care provider was evaluated using a three-stage approach--assess, advise, and assist.

RESULTS

Of those visiting a doctor in the last 3 months 22, 16, and 7% were assessed, advised, and assisted, respectively, regarding physical activity by a health care provider. At all three stages, receiving weight reduction counseling was a main variable correlated with receiving physical activity counseling (OR 3.38-2.43). Having a chronic disease was associated with being assessed; smoking and being a recent immigrant were associated with getting assistance on physical activity. Visiting a health care provider in the last 3 months, and being physically active were also associated with counseling. The dietitians and the physicians had the highest quality and rates of counseling in all three stages.

CONCLUSION

It seems that a sedentary lifestyle is not regarded as an independent risk factor during counseling, but more as an important part of weight reduction. An evaluation of physical activity counseling by the three stages can be used to assess the quality of the counseling.